Recommended Dosing of 3% Saline for Raised Intracranial Pressure
For managing raised intracranial pressure (ICP), administer 3% hypertonic saline as a bolus of 5 ml/kg over 15-20 minutes, followed by continuous infusion titrated to maintain serum sodium between 145-155 mmol/L. 1
Bolus Dosing
- For acute management of elevated ICP, administer 5 ml/kg of 3% hypertonic saline over 15-20 minutes 1
- Alternatively, a 250 ml bolus of 7.5% hypertonic saline can be used for more rapid ICP reduction, administered over 15-20 minutes 2, 1
- The maximum effect of hypertonic saline is observed after 10-15 minutes and lasts for 2-4 hours 2, 1
Continuous Infusion Protocol
- Following bolus administration, continuous infusion of 3% hypertonic saline at 0.5-1 ml/kg/hr is recommended to maintain ICP control 1, 3
- Target serum sodium concentration should be 145-155 mmol/L 2, 1
- In pediatric patients with acute CNS infections, a loading dose of 10 ml/kg followed by 0.5-1 ml/kg/hr infusion has shown efficacy 3
Monitoring Requirements
- Measure serum sodium levels within 6 hours of bolus administration 2, 1
- Do not re-administer hypertonic saline until serum sodium concentration is < 155 mmol/L 2, 1
- Monitor for hypernatremia and hyperchloremia, especially with continuous infusions 2
- Continuous ICP monitoring is recommended during therapy 2
Efficacy and Safety Considerations
- 3% hypertonic saline has been shown to be effective in reducing ICP in traumatic brain injury and subarachnoid hemorrhage 2, 1
- Studies have demonstrated that 3% hypertonic saline is more effective than 20% mannitol in controlling ICP in pediatric patients 3, 4
- Continuous micro-pump infusion of 3% hypertonic saline (sometimes combined with furosemide) has shown efficacy in maintaining ICP control 5
- Despite effectiveness in reducing ICP, there is no evidence that hypertonic saline improves neurological outcomes or survival 2, 1
Important Caveats
- Hypertonic saline should be used instead of and not in conjunction with mannitol for this indication 2, 1
- Avoid rapid or excessive correction of serum sodium to prevent osmotic demyelination syndrome 2
- No evidence of osmotic demyelination syndrome has been reported with proper monitoring, even with higher concentrations of hypertonic saline 2, 6
- In pediatric patients with traumatic brain injury, sustained hypernatremia (with mean highest serum sodium of 170.7 mEq/L) has been safely tolerated, though careful monitoring is required 7
- For more severe, refractory cases of intracranial hypertension, higher concentrations such as 7.5% or even 23.4% hypertonic saline may be considered 2, 6