What is the dosage of 3% NaCl (sodium chloride) for intracerebral hemorrhage?

Dosage of 3% NaCl for Intracerebral Hemorrhage

For patients with intracerebral hemorrhage, 3% hypertonic saline should be administered as a continuous infusion with a target serum sodium concentration of 145-155 mmol/L to reduce intracranial pressure. 1, 2

Administration Guidelines

Bolus Administration

• For acute elevation of intracranial pressure or signs of brain herniation, administer 3% NaCl as a bolus of 250-500 mL over 15-20 minutes 2, 3
• Bolus administration can be safely delivered peripherally at rates up to 999 mL/h without risk of extravasation or phlebitis in emergency situations 3
• Serum sodium levels should be measured within 6 hours of bolus administration to guide further therapy 1

Continuous Infusion

• Following bolus administration, transition to continuous infusion of 3% NaCl with target serum sodium concentration of 145-155 mmol/L 1, 2
• Continuous infusion may be maintained for several days (median 13 days in one study) based on clinical response and intracranial pressure measurements 4
• Monitor serum sodium and chloride levels regularly to avoid hypernatremia exceeding 155 mmol/L 1, 2

Efficacy and Monitoring

• 3% NaCl has been shown to effectively reduce intracranial pressure in intracerebral hemorrhage, with maximum effect observed after 10-15 minutes and lasting for 2-4 hours 2, 5
• In a canine model of intracerebral hemorrhage, 3% NaCl (5.3 mL/kg) demonstrated longer duration of action in reducing intracranial pressure compared to mannitol, with significant reduction in ICP maintained at 120 minutes post-administration 5
• Continuous monitoring of intracranial pressure is recommended when using hypertonic saline for intracerebral hemorrhage 1

Safety Considerations

• Avoid serum sodium levels exceeding 155-160 mmol/L to prevent complications 2
• Monitor for hyperchloremia (chloride ≥ 115 mmol/L), which has been associated with increased in-hospital mortality in ICH patients treated with continuous 3% hypertonic saline infusion 6
• Re-administration of hypertonic saline should not occur until serum sodium concentration is < 155 mmol/L 1
• No evidence of osmotic demyelination syndrome has been reported with proper monitoring of hypertonic saline therapy 1

Clinical Outcomes

• Early continuous infusion of 3% hypertonic saline in patients with cerebrovascular disease may reduce the frequency of intracranial pressure crises and mortality rates 4
• Despite effectiveness in reducing intracranial pressure, there is insufficient evidence from randomized controlled trials to confirm that hypertonic saline improves neurological outcomes in adults with acute ICH 1
• Moderate hyperchloremia (chloride ≥ 115 mmol/L) during treatment with continuous 3% hypertonic saline has been independently associated with increased in-hospital mortality (OR 4.4,95% CI 1.4-13.5) 6

Comparison with Other Agents

• Hypertonic saline has shown comparable or superior efficacy to mannitol in reducing intracranial pressure 2, 5
• Unlike mannitol, hypertonic saline may be preferred in patients with hypovolemia 2
• Glycerol and mannitol have been tested in randomized controlled trials for ICH with no apparent benefits on mortality or neurological outcomes 1

Important Caveats

• Despite the widespread use of hypertonic saline in clinical practice, there is insufficient evidence from randomized controlled trials to make strong recommendations on measures to lower intracranial pressure for adults with acute ICH 1
• Hypertonic saline is not recommended as a solution for volume resuscitation in patients with hemorrhagic shock 1
• In situations combining hemorrhagic shock with severe head trauma and focal neurological signs, administration of hypertonic saline bolus may be considered due to its osmotic effect 1