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Abstract

Introduction: Hypertonic saline (HTS) remains a cornerstone of therapy in current treatment guidelines for traumatic brain injury (TBI), intracranial hemorrhage (ICH), ischemic stroke (IS), and subarachnoid hemorrhage (SAH) in order to provide optimal management of intracranial pressure (ICP) following initial brain injury. HTS is available in several concentrations and is often used as a continuous or intermittent infusion; however there is limited data on the intermittent use of 23.4% HTS in severe brain injury. Methods: Critically-ill patients receiving 23.4% HTS following brain injury between 2012 and 2013 were included in this single-center, retrospective study. Data collected include patient demographics, concomitant use of HTS continuous infusions, mean arterial pressure (MAP), and ICP values during use of 23.4% HTS therapy. The primary endpoint used to determine efficacy was mean change in ICP following administration of intermittent HTS. Secondary endpoints used to determine safety include post-infusion electrolyte abnormalities, hemodynamic data, and physician ordering characteristics. Demographic data, primary, and secondary endpoints were analyzed using descriptive statistics. Results: Twenty-one patients were evaluated with demographics as follows: average age 39 years, mean admission GCS 6.2, and mean ICP 15.4 mmHg. Indications for HTS therapy include TBI (52.4%), ICH (9.5%), SAH (23.8%), IS (9.5%) and intraventricular hemorrhage (4.8%). Mean length of HTS therapy was 3.1 days with an average of 5.4 doses administered per patient. Mean ICP before and after 23.4% HTS boluses were 25.4 mmHg and 18.2 mmHg, respectively. A total of 114 HTS boluses resulted in 104 reductions in ICP. Mean percentage decrease in ICP after administration of 23.4% HTS was 29.7. ICP values decreased by an average of 7.1 mmHg following doses of 23.4% HTS. Average serum sodium and serum osmolality concentrations following HTS administration increased by 1.3 mEq/L and 4.4 mOsm/kg, respectively. Mean MAP and CPP during HTS therapy were 95.8 mmHg and 76.2 mmHg, respectively. Conclusions: Significant reductions in ICP were seen following administration of 23.4% HTS boluses. Significant increases in serum sodium and serum osmolality, as well as changes in hemodynamics after HTS boluses were not observed. Overall, intermittent doses of 23.4% HTS appear to be a safe and effective treatment for the management of increased ICP following severe brain injury.