What is the appropriate method for administering a hypertonic solution to a patient with impending herniation due to traumatic brain injury, characterized by anisocoria, fixed dilation of the left pupil, and midline shift, with vital signs indicating tachycardia, hypotension, hypoxia, and tachypnea?

From the Guidelines

For a patient with impending herniation due to traumatic brain injury, the appropriate hypertonic solution would be hypertonic sodium chloride 3% administered as a rapid bolus of 250 mL via a peripherally inserted 20-gauge intravenous catheter in the upper arm. This option provides the correct concentration and volume needed to rapidly reduce intracranial pressure in this emergency situation. Hypertonic saline works by creating an osmotic gradient that pulls fluid from the brain tissue into the vasculature, thereby decreasing cerebral edema and intracranial pressure. The 3% concentration is effective while being safer than higher concentrations for peripheral administration, as noted in studies such as 1. The 250 mL volume provides an adequate dose to achieve the desired osmotic effect. Using a 20-gauge catheter in the upper arm ensures adequate flow rate for the rapid bolus needed in this time-sensitive situation. This approach aligns with emergency protocols for managing acute cerebral edema and impending herniation, where immediate intervention is critical to prevent further neurological deterioration and potentially fatal outcomes, as discussed in 1 and 1. Key considerations include:

• The need for rapid reduction of intracranial pressure to prevent further brain injury
• The choice of hypertonic solution concentration and volume based on current evidence
• The method of administration, including catheter size and location, to ensure effective and safe delivery of the hypertonic solution
• The importance of monitoring for potential adverse effects, as mentioned in 1, while prioritizing the urgent need to reduce intracranial pressure.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION: The dosage of Sodium Chloride Injection, USP, 23. 4%, as an additive in parenteral fluid therapy is predicated on specific requirements of the patient after necessary clinical and laboratory information is considered and correlated. The FDA drug label does not answer the question.

From the Research

Hypertonic Solution Administration

To treat the patient's impending herniation, a hypertonic solution can be administered. The following options are available:

• Acquire hypertonic sodium chloride 3% from a locked pocket of the automated dispensing cabinet and administer a rapid bolus of 250 mL via a peripherally inserted 20-gauge intravenous catheter in the upper arm.
• Place a “STAT” order for hypertonic sodium chloride 2% 100 mL to be compounded by the central pharmacy and sent via pneumatic tube to the emergency department for administration via a peripherally inserted 18-gauge catheter in the upper arm.
• Acquire a vial of hypertonic sodium chloride 23.4% from the clean supply room and administer 30 mL via rapid intravenous (IV) push through a peripherally inserted 20-gauge intravenous catheter in the antecubital fossa.
• Acquire sodium bicarbonate 8.4% from the automated dispensing cabinet and administer 1 ampule (50 mL) via a peripherally inserted 18-gauge catheter in the upper arm.

Safety and Efficacy of Hypertonic Solutions

Studies have shown that hypertonic sodium chloride can be safely administered peripherally in emergent situations. For example, a study by Holden and colleagues found that rapid, peripheral administration of 3% hypertonic saline boluses is a safe alternative for treatment of neurologic emergencies 2. Another study found that hypertonic saline as a single osmotic agent decreased intracranial pressure while improving cerebral perfusion pressure and brain tissue oxygen in patients with severe traumatic brain injury 3.

Administration Guidelines

The following guidelines can be followed for administering hypertonic solutions:

• Hypertonic sodium chloride 3% can be administered peripherally at a rate of up to 999 mL/h without resulting in extravasation or phlebitis 2.
• Hypertonic sodium chloride 23.4% can be administered in a dose of 30 mL over 15 minutes for intracranial hypertension 3.
• Lower concentrations of hypertonic saline, such as 3% and 7.5%, are commonly used and have been shown to be effective in reducing intracranial pressure and improving Glasgow Coma Scale score 4.

Comparison of Hypertonic Solutions

A systematic review and meta-analysis found that hypertonic saline was associated with adverse hypernatremia compared to other intracranial-pressure-lowering agents, but there was no evidence of an effect on clinically important outcomes 5. Another study found that mannitol was effective in reducing intracranial pressure and carried a mortality benefit compared to barbiturates, but current evidence regarding the use of hypertonic saline in severe traumatic brain injury is limited to smaller studies 6.