From the Guidelines
Hypertonic saline is an effective treatment option for managing increased intracranial pressure (ICP) in traumatic brain injury (TBI) patients, but it does not improve neurological outcomes or survival rates, as shown in a recent study 1.
Key Points
- The typical concentration of hypertonic saline used ranges from 3% to 23.4%, with 3% and 7.5% being most common for continuous infusion and 23.4% for bolus administration in emergency situations.
- For continuous infusion, 3% saline is typically administered at 0.5-1 ml/kg/hr, titrated to target serum sodium levels of 145-155 mEq/L or until ICP is controlled.
- Hypertonic saline works by creating an osmotic gradient that draws water from the brain tissue into the intravascular space, thereby reducing cerebral edema and lowering ICP.
- When administering hypertonic saline, patients should be monitored for potential side effects including electrolyte abnormalities, renal dysfunction, central pontine myelinolysis (with rapid sodium correction), and volume overload.
Administration and Monitoring
- Treatment should be conducted in an ICU setting with continuous ICP monitoring, frequent electrolyte checks, and neurological assessments.
- Hypertonic saline is generally preferred over mannitol in hemodynamically unstable patients as it provides volume expansion while reducing ICP, as noted in a study 1.
Evidence and Recommendations
- A Cochrane meta-analysis 1 found that hypertonic saline reduces ICP, but does not improve neurological outcomes or survival rates.
- The European guideline for the management of bleeding and coagulopathy following major trauma recommends the use of hypertonic saline in the treatment algorithm for raised intracranial pressure, but notes that it does not improve neurological outcomes or survival rates 1.
- Overall, the evidence suggests that hypertonic saline is a safe and effective treatment option for managing increased ICP in TBI patients, but its use should be carefully considered and monitored due to potential side effects and lack of improvement in neurological outcomes or survival rates.
From the Research
Hypertonic Saline in Treatment of Traumatic Brain Injury
- Hypertonic saline has been compared to mannitol for the management of elevated intracranial pressure in traumatic brain injury, with studies suggesting that hypertonic saline may have lower treatment failure and lower intracranial pressure 30-60 minutes after infusion termination 2.
- A systematic review of clinical protocols reported in the neurosurgical and neurocritical care literature found that various concentrations of hypertonic saline, including 3%, 5%, 7.2%, 7.5%, and 20%, were used, and that infusions of 3% and 7.5% hypertonic saline were the most commonly used concentrations 3.
- A meta-analysis of randomized controlled trials found that hypertonic saline had no significant effect on favorable outcome or mortality compared to mannitol, but had significantly lower intracranial pressure 90-120 minutes after treatment and higher cerebral perfusion pressure 30-60 and 90-120 minutes after treatment 4.
- A systematic review and meta-analysis found that hypertonic saline was no better than mannitol in efficacy and safety in the long-term management of acute traumatic brain injury, but that the evidence quality was very low due to imprecision, indirectness, and risk of bias 5.
- A review of the literature found that hypertonic saline is an effective alternative to mannitol for increased intracranial pressure, and that further research is needed to compare these two agents for superiority in the management of increased intracranial pressure 6.
Key Findings
- Hypertonic saline may have lower treatment failure and lower intracranial pressure 30-60 minutes after infusion termination compared to mannitol 2.
- Infusions of 3% and 7.5% hypertonic saline are the most commonly used concentrations 3.
- Hypertonic saline has no significant effect on favorable outcome or mortality compared to mannitol, but has significantly lower intracranial pressure 90-120 minutes after treatment and higher cerebral perfusion pressure 30-60 and 90-120 minutes after treatment 4.
- The evidence quality for the comparison of hypertonic saline and mannitol is very low due to imprecision, indirectness, and risk of bias 5.
- Further research is needed to compare hypertonic saline and mannitol for superiority in the management of increased intracranial pressure 6.