From the Guidelines
Hypertonic saline is effective in reducing elevated Intracranial Pressure (ICP) regardless of whether it is administered as a continuous infusion or bolus, but the choice between the two methods depends on the specific clinical context and patient needs.
Comparison of Administration Methods
- Bolus administration is commonly used in clinical practice, with most studies utilizing 7.5% hypertonic saline boluses 1.
- Continuous infusion is also effective, typically using 3% hypertonic saline, and may be beneficial in certain patient populations, such as those with acute liver failure or children with traumatic brain injury 1.
Key Considerations
- The majority of studies have used bolus doses, but there is evidence to suggest that continuous infusions can be effective in reducing ICP 1.
- The optimal duration of treatment and the most effective concentration of hypertonic saline are unclear and require further study 1.
- Hypertonic saline is recommended for use in the treatment algorithm for raised ICP, but it should be used instead of, not in conjunction with, mannitol for this indication 1.
Safety and Efficacy
- Current evidence confirms that hypertonic saline is effective in reducing raised ICP (Grade A), but does not improve neurological outcomes (Grade B) or survival in states of raised ICP (Grade A) 1.
- The safety profile of hypertonic saline is generally favorable, with few reported adverse effects, but monitoring for adverse effects, such as osmotic demyelination syndrome, is essential 1.
From the Research
Comparison of Continuous Infusion and Bolus Administration of Hypertonic Saline
- The study 2 compared the effects of bolus versus continuous infusion of hypertonic saline (HTS) on intracranial pressure (ICP) in traumatic brain injury patients, and found that although time to goal osmolality was similar between cohorts, the continuous group had a higher percentage of patients achieving goal osmolality.
- The literature review 3 suggested that HTS given as either a bolus or continuous infusion can be effective in reducing episodes of elevated ICP, and a meta-analysis of 8 prospective RCTs showed a higher rate of treatment failure or insufficiency with mannitol or normal saline versus HTS.
- The rodent model study 4 found that HTS was more effective than mannitol in reducing elevated ICP, with a 53.9% reduction versus 35.0% (P < .01), and the therapeutic action of HTS was more durable.
Administration Methods and Efficacy
- The systematic review and meta-analysis 5 found that hypertonic saline appears to reduce intracranial pressure in children with cerebral edema, but the safest dose regimens, including the safe and effective therapeutic hypernatremia threshold, are unclear.
- The case report 6 highlighted the effectiveness of hypertonic saline in managing elevated ICP in a patient with intracranial bleed, with the patient receiving total of 17 doses of 23.4% HS and 30 doses of mannitol with good outcome.
Safety and Adverse Effects
- The study 2 found that rates of hypernatremia were similar between bolus and continuous infusion groups, but significant higher rates of hyperchloremia and acute kidney injury (AKI) were observed in the continuous cohort.
- The systematic review and meta-analysis 5 reported adverse events in three studies, but not methodically, and there were no reports on neurological sequelae.