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

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


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and 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 two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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