Hypertonic Saline
CLASS
- concentrated Sodium chloride
MECHANISM OF ACTION
- elevation of the serum Na+
PHARMACEUTICS
- 3% (513mEq/L)
- 5% (856mEq/L)
- 23.4% (4000mEq/L)
- should be given by CVL due to phlebitis and tissue necrosis
DOSE
- titrated to Na+ of 155mmol/L
INDICATIONS
- raise serum Na+ in severe, symptomatic hyponatraemia (< 120mmol/L) to treat cerebral oedema
- treat raised intracranial pressure
- other conditions where Na+ loss is large: cerebral salt wasting or large GI losses
ADVANTAGES
- rapid effect (peak @ 10 min, lasts 1 hour)
- end point of therapy Na+ 145-155 (easily monitored via ABG)
- less likely to produce hypovolaemia (compared with mannitol)
- rapid restoration of intravascular volume, BP and decreases ICP
- may have a better effect on CBF for a given reduction in ICP
- may prevent cerebral oedema
- higher reflection coefficient at the blood brain barrier than mannitol
- can be used as a continuous infusion
- doesn’t need osmolality testing
- cheap, available
- easy to transport (small volume)
- anti-inflammatory effect may decrease incidence of MODS
DISADVANTAGES
- hypernatraemia
- hyperchloraemic acidaemia
- renal failure
- need for CVL
- phlebitis
- tissue necrosis if extravasates
- central pontine myelinosis if Na+ corrected too quickly in hyponatraemia
- hypokalaemia
- lack of outcome data
- increase in circulating volume -> risk of CHF (theoretical – not recorded)
- coagulopathy: can affect APTT, INR and platelet aggregation (no evidence for changes in outcome)
- rapid changes in Na+ may result in seizures and encephalopathy
- some suggest it affects normal brain more than injured -> may worsen herniation
- rebound intracranial hypertension
EVIDENCE
Cooper, DJ. Hypertonic Saline Resuscitation for Head Injured Patients. Critical Care and Resusctiation 1999: 1:157-161
- review to establish equipoise for an RCT
Cooper DJ, et al. Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial. JAMA 2004;291:1350-1357.
- double blind RCT
- n = 229
- traumatic brain injury + coma and hypotensive
- given 250mL 7.5% saline vs 250mL Hartmans + normal resuscitation protocols
-> no difference in survival or neurological outcome @ 6 months
References and Links
Introduction to ICU Series
Introduction to ICU Series Landing Page
DAY TO DAY ICU: FASTHUG, ICU Ward Round, Clinical Examination, Communication in a Crisis, Documenting the ward round in ICU, Human Factors
AIRWAY: Bag Valve Mask Ventilation, Oropharyngeal Airway, Nasopharyngeal Airway, Endotracheal Tube (ETT), Tracheostomy Tubes
BREATHING: Positive End Expiratory Pressure (PEEP), High Flow Nasal Prongs (HFNP), Intubation and Mechanical Ventilation, Mechanical Ventilation Overview, Non-invasive Ventilation (NIV)
CIRCULATION: Arrhythmias, Atrial Fibrillation, ICU after Cardiac Surgery, Pacing Modes, ECMO, Shock
CNS: Brain Death, Delirium in the ICU, Examination of the Unconscious Patient, External-ventricular Drain (EVD), Sedation in the ICU
GASTROINTESTINAL: Enteral Nutrition vs Parenteral Nutrition, Intolerance to EN, Prokinetics, Stress Ulcer Prophylaxis (SUP), Ileus
GENITOURINARY: Acute Kidney Injury (AKI), CRRT Indications
HAEMATOLOGICAL: Anaemia, Blood Products, Massive Transfusion Protocol (MTP)
INFECTIOUS DISEASE: Antimicrobial Stewardship, Antimicrobial Quick Reference, Central Line Associated Bacterial Infection (CLABSI), Handwashing in ICU, Neutropenic Sepsis, Nosocomial Infections, Sepsis Overview
SPECIAL GROUPS IN ICU: Early Management of the Critically Ill Child, Paediatric Formulas, Paediatric Vital Signs, Pregnancy and ICU, Obesity, Elderly
FLUIDS AND ELECTROLYTES: Albumin vs 0.9% Saline, Assessing Fluid Status, Electrolyte Abnormalities, Hypertonic Saline
PHARMACOLOGY: Drug Infusion Doses, Summary of Vasopressors, Prokinetics, Steroid Conversion, GI Drug Absorption in Critical Illness
PROCEDURES: Arterial line, CVC, Intercostal Catheter (ICC), Intraosseous Needle, Underwater seal drain, Naso- and Orogastric Tubes (NGT/OGT), Rapid Infusion Catheter (RIC)
INVESTIGATIONS: ABG Interpretation, Echo in ICU, CXR in ICU, Routine daily CXR, FBC, TEG/ROTEM, US in Critical Care
ICU MONITORING: NIBP vs Arterial line, Arterial Line Pressure Transduction, Cardiac Output, Central Venous Pressure (CVP), CO2 / Capnography, Pulmonary Artery Catheter (PAC / Swan-Ganz), Pulse Oximeter
CCC Neurocritical Care Series
Emergencies: Brain Herniation, Eclampsia, Elevated ICP, Status Epilepticus, Status Epilepticus in Paeds
DDx: Acute Non-Traumatic Weakness, Bulbar Dysfunction, Coma, Coma-like Syndromes, Delayed Awakening, Hearing Loss in ICU, ICU acquired Weakness, Post-Op Confusion, Pseudocoma, Pupillary Abnormalities
Neurology: Anti-NMDA Encephalitis, Basilar Artery Occlusion, Central Diabetes Insipidus, Cerebral Oedema, Cerebral Venous Sinus Thrombosis, Cervical (Carotid / Vertebral) Artery Dissections, Delirium, GBS vs CIP, GBS vs MG vs MND, Guillain-Barre Syndrome, Horner’s Syndrome, Hypoxic Brain Injury, Intracerebral Haemorrhage (ICH), Myasthenia Gravis, Non-convulsive Status Epilepticus, Post-Hypoxic Myoclonus, PRES, Stroke Thrombolysis, Transverse Myelitis, Watershed Infarcts, Wernicke’s Encephalopathy
Neurosurgery: Cerebral Salt Wasting, Decompressive Craniectomy, Decompressive Craniectomy for Malignant MCA Syndrome, Intracerebral Haemorrhage (ICH)
— SCI: Anatomy and Syndromes, Acute Traumatic Spinal Cord Injury, C-Spine Assessment, C-Spine Fractures, Spinal Cord Infarction, Syndomes,
— SAH: Acute management, Coiling vs Clipping, Complications, Grading Systems, Literature Summaries, ICU Management, Monitoring, Overview, Prognostication, Vasospasm
— TBI: Assessment, Base of skull fracture, Brain Impact Apnoea, Cerebral Perfusion Pressure (CPP), DI in TBI, Elevated ICP, Limitations of CT, Lund Concept, Management, Moderate Head Injury, Monitoring, Overview, Paediatric TBI, Polyuria incl. CSW, Prognosis, Seizures, Temperature
ID in NeuroCrit. Care: Aseptic Meningitis, Bacterial Meningitis, Botulism, Cryptococcosis, Encephalitis, HSV Encephalitis, Meningococcaemia, Spinal Epidural Abscess
Equipment/Investigations: BIS Monitoring, Codman ICP Monitor, Continuous EEG, CSF Analysis, CT Head, CT Head Interpretation, EEG, Extradural ICP Monitors, External Ventricular Drain (EVD), Evoked Potentials, Jugular Bulb Oxygen Saturation, MRI Head, MRI and the Critically Ill, Train of Four (TOF), Transcranial Doppler
Pharmacology: Desmopressin, Hypertonic Saline, Levetiracetam (Keppra), Mannitol, Midazolam, Sedation in ICU, Thiopentone
MISC: Brainstem Rules of 4, Cognitive Impairment in Critically Ill, Eye Movements in Coma, Examination of the Unconscious Patient, Glasgow Coma Scale (GCS), Hiccoughs, Myopathy vs Neuropathy, Neurology Literature Summaries, NSx Literature Summaries, Occulocephalic and occulovestibular reflexes, Prognosis after Cardiac Arrest, SIADH vs Cerebral Salt Wasting, Sleep in ICU
Journal articles
- Cooper DJ, Myles PS, McDermott FT. Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial. JAMA. 291(11):1350-7. 2004. [pubmed]
- Cooper DJ. Hypertonic saline resuscitation for head injured patients. Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine. 1(2):161. 1999. [pubmed]
- Hinson HE, Stein D, Sheth KN. Hypertonic saline and mannitol therapy in critical care neurology. Journal of intensive care medicine. 28(1):3-11. 2013. [pubmed]
- Marko NF. Hypertonic saline, not mannitol, should be considered gold-standard medical therapy for intracranial hypertension. Critical care (London, England). 16(1):113. 2012. [pubmed] [free full text]
- Mortazavi MM, Romeo AK, Deep A. Hypertonic saline for treating raised intracranial pressure: literature review with meta-analysis. Journal of neurosurgery. 116(1):210-21. 2012. [pubmed]
- White H, Cook D, Venkatesh B. The use of hypertonic saline for treating intracranial hypertension after traumatic brain injury. Anesthesia and analgesia. 102(6):1836-46. 2006. [pubmed] [Free Full Text]
FOAM and web resources
- Original Kings of County — Hypertonic saline vs mannitol (2015)
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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