3% NaCl Dosing for Raised ICP in an 11-Year-Old Child
For an 11-year-old child with raised intracranial pressure, administer 3% hypertonic saline as a continuous infusion at 0.5-1 mL/kg/hr after a loading dose of 10 mL/kg, targeting a serum sodium concentration of 145-155 mmol/L. 1, 2
Initial Bolus Dosing Options
For acute ICP management in pediatric patients, you have two evidence-based approaches:
- 5 mL/kg of 3% hypertonic saline administered over 15-20 minutes 2
- Alternatively, 2 mL/kg of 7.5% hypertonic saline can be used for more rapid ICP reduction, also given over 15-20 minutes 3
The maximum ICP-lowering effect occurs 10-15 minutes after administration and lasts 2-4 hours 1, 2
Continuous Infusion Protocol
Following the initial bolus, transition to a continuous infusion strategy:
- Start 3% hypertonic saline at 0.5-1 mL/kg/hr as a continuous infusion 1
- Target serum sodium: 145-155 mmol/L to maintain sustained ICP control 1, 2
- This approach has been specifically validated in pediatric traumatic brain injury patients with mean treatment duration of 7.6 days 4, 5
Pediatric-Specific Evidence
The continuous infusion approach is particularly well-supported in children:
- A prospective pediatric study demonstrated that 3% hypertonic saline infusions (10 mL/kg loading followed by continuous infusion) achieved target ICP <20 mmHg in 79.3% of children versus only 53.6% with mannitol 6
- Children treated with 3% hypertonic saline had significantly lower mean ICP over 72 hours (14 vs 22 mmHg) and higher cerebral perfusion pressure (65 vs 58 mmHg) compared to mannitol 6
- Retrospective data from 68 children receiving 3% hypertonic saline infusions showed no adverse effects, including no evidence of osmotic demyelination syndrome 4, 7
Critical Monitoring Requirements
Measure serum sodium within 6 hours of bolus administration and do not re-administer until serum sodium is <155 mmol/L 4, 1, 2
Additional monitoring parameters:
- Continuous ICP monitoring during therapy 2
- Monitor for hypernatremia and hyperchloremia, especially with continuous infusions 1, 2
- In pediatric studies, mean highest serum sodium reached 170.7 mmol/L (range 157-187 mmol/L) without adverse effects when properly monitored 4, 5
Superiority Over Mannitol
Use hypertonic saline instead of—not in conjunction with—mannitol for raised ICP 4, 1, 2
The evidence strongly favors hypertonic saline in pediatric populations:
- 3% hypertonic saline produced greater ICP reduction (-14.3 vs -5.4 mmHg) compared to 20% mannitol in children with CNS infections 6
- Children receiving hypertonic saline had shorter mechanical ventilation duration (5 vs 15 days) and PICU stay (11 vs 19 days) 6
- Lower mortality (20.7% vs 35.7%) and less severe neurodisability at discharge (31% vs 61%) were observed with hypertonic saline 6
Important Safety Considerations
Despite effectiveness in reducing ICP:
- No evidence exists that hypertonic saline improves neurological outcomes (Grade B) or survival (Grade A) in patients with raised ICP 4, 1, 2
- Avoid rapid or excessive sodium correction to prevent osmotic demyelination syndrome 1, 2
- However, no cases of osmotic demyelination syndrome have been reported with proper monitoring, even with sustained hypernatremia 4, 7
Common Pitfalls to Avoid
- Do not exceed serum sodium of 155-160 mmol/L without careful consideration 1
- Do not use hypertonic saline for volume resuscitation in hemorrhagic shock 1
- Ensure adequate monitoring infrastructure before initiating therapy, as continuous ICP monitoring is essential 2
- Re-bolusing may be necessary every 163 ± 54 minutes when ICP-lowering effect is transient 3