From the Guidelines
The sodium goal in subdural hematoma should be to maintain serum sodium levels between 145-155 mmol/L, as this range has been shown to reduce intracranial pressure and improve outcomes in patients with acute liver failure and elevated intracranial pressure 1. This mild to moderate hypernatremia can be achieved through controlled hypertonic saline administration, often using 3% saline solutions.
Key Considerations
- The initial approach may involve bolus doses of 3% saline (100-250 mL) followed by continuous infusion at 0.5-1 mL/kg/hr, with frequent monitoring of serum sodium levels every 4-6 hours 1.
- The rate of infusion should be adjusted based on sodium levels and clinical response, with the goal of maintaining serum sodium levels within the target range.
- This hypernatremic state helps reduce intracranial pressure by creating an osmotic gradient that pulls water from brain tissue into the bloodstream, thereby decreasing cerebral edema.
- The elevated sodium levels should be maintained during the acute phase of injury, typically 3-5 days, and then gradually normalized at a rate not exceeding 10 mEq/L per 24 hours to avoid rapid fluid shifts that could worsen cerebral edema.
Monitoring and Complications
- Close monitoring for complications such as pulmonary edema, heart failure, and central pontine myelinolysis is essential during this therapy 1.
- Fluid restriction may be implemented concurrently, and serum osmolality should be maintained below 320 mOsm/kg to minimize adverse effects.
- The majority of patients had peak levels < 155 mmol.l-1, and there were no adverse effects thought to be related to hypertonic saline infusion 1.
Evidence-Based Recommendation
Maintaining serum sodium levels between 145-155 mmol/L is a safe and effective strategy for reducing intracranial pressure in patients with subdural hematoma, as supported by the most recent and highest quality study 1.
From the Research
Sodium Goal in Subdural Hematoma
- The ideal sodium goal in subdural hematoma is not explicitly stated in the provided studies 2, 3, 4, 5.
- However, a study on aneurysmal subarachnoid hemorrhage found that both hyponatremia and hypernatremia were associated with unfavorable neurologic outcomes, with optimal serum sodium levels between 132-145 mmol/L 6.
- Although this study is not directly related to subdural hematoma, it suggests that maintaining normonatremia may be important in patients with intracranial hemorrhage.
- The management of subdural hematoma focuses on decompression of neural tissue, restoration of perfusion, and maintenance of adequate cerebral perfusion, with medical care including management of intracranial hypertension, seizure prevention, and maintenance of normothermia, eucarbia, euglycemia, and euvolemia 2, 3, 4, 5.