Hypertonic Saline Bolus Research Articles

Risk Factors Associated With Acute Kidney Injury in Traumatic Brain Injury Patients Treated With Hypertonic Saline: A Retrospective Study.

Background: Hypertonic saline (HTS) is essential pharmacologic treatment for traumatic brain injury (TBI). Previous studies associate HTS with acute kidney injury (AKI), however evidence in TBIs is limited. Objective: This study examines factors associated with AKI in patients requiring HTS for TBI. Methods: This retrospective study was performed at a Level-1 Trauma, Academic Medical Center. Inclusion criteria were TBI, age ≥12years, ICU length of stay ≥72hours, and administration of ≥24hours of continuous HTS or 500mL of HTS boluses. The primary outcome was identifying factors associated with AKI. Secondary outcomes included correlation between chloride load and level with development of AKI. Chloride load was calculated from HTS and non-HTS sources. Results: Of 129 patients included, 18 (14%) developed AKI. Maximum sodium level was higher in the AKI group (P < 0.0001). Hyperchloremia (Cl ≥ 115 mEq/L) was more common in the AKI group (100% vs 81%, P = 0.0428). Maximum and change in serum chloride were higher in the AKI group (median 128 vs 123 mEq/L, P = 0.0026 and +24 mEq/L vs +17 mEq/L, P = 0.0084, respectively). Logistic regression analysis indicated an OR 1.095 times higher [95% CI (1.022, 1.172)] for developing AKI for every one mEq/L increase in maximum chloride level and an OR 1.032 [95% CI (1.006, 1.058)] for developing AKI for every 1-year increase in age. There was no difference in total chloride load between groups (P = 0.2143). Non-HTS sources provided more than 40% of total chloride load in both groups. Conclusion: Chloride level, and age may be associated with AKI in TBI patients treated with HTS.

Safety and Effect on Intracranial Pressure of 3% Hypertonic Saline Bolus Via Peripheral Intravenous Catheter for Neurological Emergencies.

Elevated intracranial pressure (ICP) is a neurological emergency in patients with acute brain injuries. Such a state requires immediate and effective interventions to prevent potential neurological deterioration. Current clinical guidelines recommend hypertonic saline (HTS) and mannitol as first-line therapeutic agents. Notably, HTS is conventionally administered through central venous catheters (CVCs), which may introduce delays in treatment due to the complexities associated with CVC placement. These delays can critically affect patient outcomes, necessitating the exploration of more rapid therapeutic avenues. This study aimed to investigate the safety and effect on ICP of administering rapid boluses of 3% HTS via peripheral intravenous (PIV) catheters. A retrospective cohort study was performed on patients admitted to Sisters of Saint Mary Health Saint Louis University Hospital from March 2019 to September 2022 who received at least one 3% HTS bolus via PIV at a rate of 999mL/hour for neurological emergencies. Outcomes assessed included complications related to 3% HTS bolus and its effect on ICP. Of 216 3% HTS boluses administered in 124 patients, complications occurred in 8 administrations (3.7%). Pain at the injection site (4 administrations; 1.9%) and thrombophlebitis (3 administrations; 1.4%) were most common. The median ICP reduced by 6mm Hg after 3% HTS bolus administration (p < 0.001). Rapid bolus administration of 3% HTS via PIV catheters presents itself as a relatively safe approach to treat neurological emergencies. Its implementation could provide an invaluable alternative to the traditional CVC-based administration, potentially minimizing CVC-associated complications and expediting life-saving interventions for patients with neurological emergencies, especially in the field and emergency department settings.

Modulation of pulmonary blood flow in patients with acute respiratory failure

BackgroundImpairment of ventilation and perfusion (V/Q) matching is a common mechanism leading to hypoxemia in patients with acute respiratory failure requiring intensive care unit (ICU) admission. While ventilation has been thoroughly investigated, little progress has been made to monitor pulmonary perfusion at the bedside and treat impaired blood distribution. The study aimed to assess real-time changes in regional pulmonary perfusion in response to a therapeutic intervention. MethodsSingle-center prospective study that enrolled adult patients with ARDS caused by SARS-Cov-2 who were sedated, paralyzed, and mechanically ventilated. The distribution of pulmonary perfusion was assessed through electrical impedance tomography (EIT) after the injection of a 10-ml bolus of hypertonic saline. The therapeutic intervention consisted in the administration of inhaled nitric oxide (iNO), as rescue therapy for refractory hypoxemia. Each patient underwent two 15-min steps at 0 and 20 ppm iNO, respectively. At each step, respiratory, gas exchange, and hemodynamic parameters were recorded, and V/Q distribution was measured, with unchanged ventilatory settings. ResultsTen 65 [56–75] years old patients with moderate (40%) and severe (60%) ARDS were studied 10 [4-20] days after intubation. Gas exchange improved at 20 ppm iNO (PaO2/FiO2 from 86 ± 16 to 110 ± 30 mmHg, p = 0.001; venous admixture from 51 ± 8 to 45 ± 7%, p = 0.0045; dead space from 29 ± 8 to 25 ± 6%, p = 0.008). The respiratory system's elastic properties and ventilation distribution were unaltered by iNO. Hemodynamics did not change after gas initiation (cardiac output 7.6 ± 1.9 vs. 7.7 ± 1.9 L/min, p = 0.66). The EIT pixel perfusion maps showed a variety of patterns of changes in pulmonary blood flow, whose increase positively correlated with PaO2/FiO2 increase (R2 = 0.50, p = 0.049). ConclusionsThe assessment of lung perfusion is feasible at the bedside and blood distribution can be modulated with effects that are visualized in vivo. These findings might lay the foundations for testing new therapies aimed at optimizing the regional perfusion in the lungs.

Hypertonic Saline Solution versus Mannitol in Children with Intracranial Hypertension: A Systematic Review and Meta-Analysis (P11-7.002)

<h3>Objective:</h3> We aimed to perform a systematic review and meta-analysis on the efficacy of hypertonic saline (HS) versus mannitol (MAN), as hyperosmolar agents, in children with elevated intracranial pressure. <h3>Background:</h3> Hyperosmolar therapy may reduce intracranial hypertension (IH) and act as a lifesaving method in critically ill patients with IH. There is no established superiority of either HS or MAN, the most frequently used agents, in pediatric patients. <h3>Design/Methods:</h3> PubMed, Embase, and Cochrane databases were searched for studies and abstracts published up to October 1st, 2022. Studies were excluded if boluses of HS or MAN were held in patients undergoing elective procedures. The outcomes of interest were mortality; changes in intracranial pressure (ICP); and changes in cerebral perfusion pressure (CPP). <h3>Results:</h3> Six studies with 819 patients were included. The mean patient age ranged from 9 months to 13.5 years. Mortality was not significantly different between the HS (15.6%) and the MAN (21.6%) groups (risk ratio [RR] 0.66; 95% confidence interval [CI] 0.44,0.99; p=0.05). There were also no significant changes in ICP (standardized mean difference −0.25; 95% CI −0.90,0.40; p=0.45) or CPP (standardized mean difference 0.20; 95% CI −0.29,0.68; p=0.42) between patients treated with HS or MAN. <h3>Conclusions:</h3> In this meta-analysis including 819 children with elevated intracranial pressure, there was no difference in mortality, ICP, or CPP between patients treated with HS or MAN. <b>Disclosure:</b> Mr. Menegaz de Almeida has nothing to disclose. Miss Oliveira has nothing to disclose. Miss Viana has nothing to disclose. Dr. Araujo has nothing to disclose. Ms. Oliveira has nothing to disclose. Ms. Dantas has nothing to disclose. Ms. Rodrigues has nothing to disclose. Miss Silva has nothing to disclose. Miss Cordeiro Rocha has nothing to disclose. Dr. Campello Jorge has nothing to disclose. Ms. Godoi has nothing to disclose. Mrs. Reis Marques has nothing to disclose. Mrs. Garcia has nothing to disclose. Miss Barreiros has nothing to disclose. Miss Toguchi has nothing to disclose. Mr. Dos Santos-Bezerra has nothing to disclose. Dr. Polverini has nothing to disclose.

Safety of peripheral 3% hypertonic saline bolus administration for neurologic emergency

Background/objectiveHypertonic sodium chloride (HTS) is used for emergent treatment of acute cerebral edema and other neurologic emergencies. Central access is not commonly available in emergent situations and 3% HTS is utilized peripherally. Many studies have shown the safety of its administration at rates up to 75 mL/h, but there is a lack of data to establish the safety of peripherally administered, rapid bolus dosing in emergent situations. The objective of this study is to describe the safety of rapid, peripherally administered (≥ 250 mL/h) 3% HTS for neurologic emergencies. MethodsThis is a retrospective, cohort study including adult patients receiving 3% HTS via a peripheral IV site for elevated intracranial pressure, cerebral edema, or other neurological emergencies at a rate of at least 250 m/h between May 5, 2018 – September 30, 2021. Patients were excluded if they simultaneously received another hypertonic saline fluid. Baseline characteristics collected included HTS dose, rate and site of administration, indication for use and patient demographics. The primary safety outcome was incidence of extravasation and phlebitis within one hour of HTS administration. ResultsThere were 206 patients receiving 3% HTS who were screened, and 37 patients met inclusion criteria. The most common reason for exclusion was administration at a rate < 250 m/h. The median age was 60 (IQR 45, 72) with 51.4% being male. The most common indications for HTS were traumatic brain injury (45.9%) and intracranial hemorrhage (37.8%). The most common administration location was the emergency department (78.4%). The median IV-gauge (n = 29) was 18 (IQR 18, 20), with the most common placement site being antecubital (48.6%). The median dose of HTS was 250 mL (IQR 250, 350), with a median administration rate of 760 mL/h (IQR 500, 999). There were no episodes of extravasation or phlebitis noted. ConclusionsRapid, peripheral administration of 3% HTS boluses is a safe alternative for treatment of neurologic emergencies. Administration at rates up to 999 mL/h did not result in extravasation or phlebitis.

Comparative study between Mannitol versus Hypertonic saline continuous infusion versus Hypertonic saline boluses in treatment of edema of traumatic brain injury

Comparative study between Mannitol versus Hypertonic saline continuous infusion versus Hypertonic saline boluses in treatment of edema of traumatic brain injury

Comparison of intermittent versus continuous infusion of 3% hypertonic saline on intracranial pressure in traumatic brain injury using ultrasound assessment of optic nerve sheath

ABSTRACT Background The employment of hypertonic saline (HTS) in intracranial hypertension treatment has been effective when administered as a continuous infusion or bolus. However, the best route and concentration are undecided because of insufficient randomized controlled trials. This study aims to function the optic nerve sheath diameter (ONSD) ultrasonographic measurements to compare the effectiveness of 3% HTS continuous infusion and intermittent boluses in reducing elevated intracranial pressure (ICP) in traumatic brain injuries (TBIs). Methods This randomized study comprised 50 patients with TBI. In all patients examined by ultrasound, we employed a cutoff value of 5.5 mm for the ONSD to predict an increase in ICP of >20 mmHg. Patients with elevated ICP were divided into two groups: group A received continuous 3% HTS infusion (0.5 mL/kg/h), and group B received intermittent 3% HTS boluses (3 mL/kg). The primary endpoint was the ONSD at 48 h. The secondary outcomes included serum Na and serum K at 6, 12, 24, 48, and 72 h. Results The ONSDs in the continuous HTS infusion and intermittent bolus groups decreased significantly and steadily, with no significant variance between the two groups at 48 h (P = 0.449). However, 3% HTS intermittent boluses caused a faster growth in sodium concentration at 6 and 12 h with noteworthy differences compared with continuous infusion (P = 0.013 and 0.001, respectively). Conclusions There were no differences in ONSD ultrasonographic values 48 h after treatment. Moreover, 3% HTS intermittent boluses caused an increase in sodium concentration at 6 and 12 h.

Hypertonic saline for severe symptomatic hyponatraemia: real-world findings from the UK.

ObjectiveTo evaluate ‘real-world’ safety and efficacy of the European Society of Endocrinology guidelines for the treatment of severe symptomatic hyponatraemia using hypertonic saline (HTS).DesignRetrospective, observational, cohort study, examining the use of HTS for severe symptomatic hyponatraemia at Sheffield Teaching Hospitals between 2017 and 2020.MethodsPatients were identified from pharmacy records and demographic, clinical, and treatment data extracted.ResultsOut of 112 patients (females:males = 61:51), the mean age ± s.d. was 66.3± 16.0 years and mean pre-treatment serum sodium ± s.d. was 113.8 ± 6.4 mmol/L. Overall, overcorrection rates at 24 and 48 h (>10 and >18 mmol/L) were 44.9 and 19.6%, respectively, while 19.6% of patients were treated for overcorrection. Above-target rise in sodium (>5 mmol/L) after first and second boluses was noted in 22.6 and 34.6% of patients, respectively. In-hospital and 12-month mortality was 7.1 and 18.7%, respectively, with no cases of osmotic demyelination. The mean venous blood gas (VBG) sodium was 1.9 mmol/L lower than paired serum sodium (n = 36) (113.6 ± 6.6 vs 115.7 ± 7.8 mmol/L).ConclusionWe report real-world data demonstrating that a significant number of patients overcorrected using current guidelines. Also, several patients had above-target rise in sodium after one bolus of HTS, and sodium measurement should be considered before the second bolus unless ongoing severe symptoms persist. A point of care VBG sodium concentration was useful for this purpose. In addition to careful monitoring, a cautious but anticipatory overcorrection prevention strategy should be considered in the first 24 h.

Comparison of Intracranial Pressure Measurements Before and After Hypertonic Saline or Mannitol Treatment in Children With Severe Traumatic Brain Injury

Hyperosmolar agents are cornerstone therapies for pediatric severe traumatic brain injury. Guideline recommendations for 3% hypertonic saline (HTS) are based on limited numbers of patients, and no study to date has supported a recommendation for mannitol. To characterize current use of hyperosmolar agents in pediatric severe traumatic brain injury and assess whether HTS or mannitol is associated with greater decreases in intracranial pressure (ICP) and/or increases in cerebral perfusion pressure (CPP). In this comparative effectiveness research study, 1018 children were screened and 18 were excluded; 787 children received some form of hyperosmolar therapy during the ICP-directed phase of care, with 521 receiving a bolus. Three of these children were excluded because they had received only bolus administration of both HTS and mannitol in the same hour, leaving 518 children (at 44 clinical sites in 8 countries) for analysis. The study was conducted from February 1, 2014, to September 31, 2017, with follow-up for 1 week after injury. Final analysis was performed July 20, 2021. Boluses of HTS and mannitol were administered. Data on ICP and CPP were collected before and after medication administration. Statistical methods included linear mixed models and corrections for potential confounding variables to compare the 2 treatments. A total of 518 children (mean [SD] age, 7.6 [5.4] years; 336 [64.9%] male; 274 [52.9%] White) were included. Participants' mean (SD) Glasgow Coma Scale score was 5.2 (1.8). Bolus HTS was observed to decrease ICP and increase CPP (mean [SD] ICP, 1.03 [6.77] mm Hg; P < .001; mean [SD] CPP, 1.25 [12.47] mm Hg; P < .001), whereas mannitol was observed to increase CPP (mean [SD] CPP, 1.20 [11.43] mm Hg; P = .009). In the primary outcome, HTS was associated with a greater reduction in ICP compared with mannitol (unadjusted β, -0.85; 95% CI, -1.53 to -0.19), but no association was seen after adjustments (adjusted β, -0.53; 95% CI, -1.32 to 0.25; P = .18). No differences in CPP were observed. When ICP was greater than 20 mm Hg, greater than 25 mm Hg, or greater than 30 mm Hg, HTS outperformed mannitol for each threshold in observed ICP reduction (>20 mm Hg: unadjusted β, -2.51; 95% CI, -3.86 to -1.15, P < .001; >25 mm Hg: unadjusted β, -3.88; 95% CI, -5.69 to -2.06, P < .001; >30 mm Hg: unadjusted β, -4.07; 95% CI, -6.35 to -1.79, P < .001), with results remaining significant for ICP greater than 25 mm Hg in adjusted analysis. In this comparative effectiveness research study, bolus HTS was associated with lower ICP and higher CPP, whereas mannitol was associated only with higher CPP. After adjustment for confounders, both therapies showed no association with ICP and CPP. During ICP crises, HTS was associated with better performance than mannitol.

The Role of Electrical Impedance Tomography for Management of High-Risk Pulmonary Embolism in a Postoperative Patient.

Electrical impedance tomography (EIT) is a non-invasive, radiation-free and bedside imaging tool that is widely used for real-time monitoring of lung ventilation. Recently, it has been proposed for use in quantitative assessment of regional lung perfusion with hypertonic saline bolus injection and consequently for pulmonary embolism (PE) detection. Here, we present a case of high-risk PE in a postoperative patient, in which EIT monitoring provided us with useful information for diagnosis and decision-making, especially with the challenge of anticoagulation and risk of bleeding.

Clinical effects of hypertonic saline boluses in children with severe traumatic brain injury.

To quantify the effects of 3% hypertonic saline (HTS) boluses on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in children. A retrospective study of patients admitted to a regional neurosurgical children's intensive care unit. A total of 156 HTS boluses were given to children with traumatic brain injury. ICP decreased 6 mmHg (P < 0.01) and CPP increased 4 mmHg (P=0.003) 1-h post-bolus. Effects persisted for 3 h post-dose ICP was 5 mmHg lower) and 4 h post-bolus CPP was 3 mmHg higher. ICP change was not associated with pre-bolus serum sodium concentration. Hypertonic saline 3% at 5 mL/kg is an effective osmolar therapy for reducing ICP and increasing CPP in children for up to 3 h. '53-53' is a suitable guide - 5 mL/kg of 3% HTS will on average decrease ICP by at least 5 mmHg for 3 h. Pre-bolus serum sodium concentration is not correlated with effect size.

A Case of Inappropriate Antidiuretic Hormone Secretion Syndrome Associated With COVID-19 Pneumonia Treated With Boluses of Hypertonic Saline for Reversal of Symptomatic Hyponatremia

Hyponatremia is the most common electrolyte disorder, which can occur in outpatients and hospitalized patients, so both first-contact doctors and specialists must keep up-to-date on the prevention, recognition, diagnosis and management of this complication.A 68-year-old male patient presents to Dos de Mayo National Hospital Emergency Department. He was diagnosed as COVID-19 pneumonia and hospitalized for management of acute respiratory failure. The patient had neurological impairment associated with poor oral tolerance. Initial laboratory examinations were C-reactive protein in 363.5 mg/L, serum sodium of 128.42 mmol/L and urine sodium was 83 meq/L. Osmolality in plasma was 266.15 mOsm/Kg and urine osmolality was 420 mOsm/Kg. Thyroid function tests as well as cortisol levels were in normal range. Our patient was diagnosed as SIAD by hyponatremia, osmolality in plasma <275 mOsm / kg, urine osmolality > 100 mOsm / kg, urine sodium > 40 mEq / l, euvolemic state and exclusion of cortisol and thyroid hormone deficiency. Treatment of hyponatremia was initiated and rapidly elevate plasma sodium by 4 meq/l in the first 6 hours. There was clinical improvement. Blood sodium levels ranged from 115 to 135 mmol/L with bolus therapy of hypertonic solutions in 72 hours. Intravenous boluses of hypertonic saline should be administered to rapidly elevate plasma sodium by 4 to 6 mEq/L in the first 6 hours. The data shows that fluid bolus therapy is more effective in acutely elevating plasma sodium than traditional low-dose hypertonic saline infusion that may lead to avoidable deaths according to recent guidelines. In this case a strategy based with bolus therapy for reversal of hyponatremia was used effectively.A number of cases of COVID-19 pneumonia are associated with SIAD. The presence of SIAD could be a clue to diagnosing COVID-19. SIAD is a major complication of COVID-19 and could be the first and only manifestation. In cases of SIAD without a clear etiology we should suspect COVID-19 in a patient with respiratory distress in the current pandemic.Syndrome of inappropiate antidiuresis (SIAD) should be assessed in every patient with COVID-19 as their treatment and early identification decreases mortality. The association between COVID-19 pneumonia and SIAD should be further identified, requiring doctors to be aware of this condition. Additional studies are required to determine the incidence and pathogenesis of SIAD in patients with COVID-19.

The impact of hypertonic saline on cerebrovascular reactivity and compensatory reserve in traumatic brain injury: an exploratory analysis.

BackgroundIntravenous hypertonic saline is utilized commonly in critical care for treatment of acute or refractory elevations of intracranial pressure (ICP) in traumatic brain injury (TBI) patients. Though there is a clear understanding of the general physiological effects of a hypertonic saline solution over long periods of time, smaller epoch effects of hypertonic saline (HTS) have not been thoroughly analyzed. The aim of this study was to perform a direct evaluation of the high-frequency response of HTS on the cerebrovascular physiological responses in TBI.MethodsWe retrospectively reviewed our prospectively maintained adult TBI database for those with archived high-frequency cerebral physiology and available HTS treatment information. We evaluated different epochs of physiology around HTS bolus dosing, comparing pre- with post-HTS. We assessed for changes in slow fluctuations in ICP, pulse amplitude of ICP (AMP), cerebral perfusion pressure (CPP), mean arterial pressure (MAP), cerebrovascular reactivity (as measured through pressure reactivity index (PRx)), and cerebral compensatory reserve (correlation (R) between AMP (A) and ICP (P)). Comparisons of mean measures and percentage time above clinically relevant thresholds for the physiological parameters were compared pre- and post-HTS using descriptive statistics and Mann-Whitney U testing. We assessed for subgroups of physiological responses using latent profile analysis (LPA).ResultsFifteen patients underwent 69 distinct bolus infusions of hypertonic saline. Apart from the well-documented decrease in ICP, there was also a reduction in AMP. The analysis of cerebrovascular reactivity response to HTS solution had two main effects. For patients with grossly impaired cerebrovascular reactivity pre-HTS (PRx > + 0.30), HTS bolus led to improved reactivity. However, for those with intact cerebrovascular reactivity pre-HTS (PRx < 0), HTS bolus demonstrated a trend towards more impaired reactivity. This indicates that HTS has different impacts, dependent on pre-bolus cerebrovascular status. There was no significant change in metrics of cerebral compensatory reserve. LPA failed to demonstrate any subgroups of physiological responses to HTS administration.ConclusionsThe direct decrease in ICP and AMP confirms that a bolus dose of a HTS solution is an effective therapeutic agent for intracranial hypertension. However, in patients with intact autoregulation, hypertonic saline may impair cerebral hemodynamics. These findings regarding cerebrovascular reactivity remain preliminary and require further investigation.Electronic supplementary materialThe online version of this article (10.1007/s00701-020-04579-0) contains supplementary material, which is available to authorized users.

Concentrated hypertonic saline in severe pediatric traumatic brain injury

ABSTRACT Objective Describe outcomes associated with bolus and continuous infusions of hypertonic saline (HTS) in children with severe traumatic brain injury (TBI). Methods IRB-approved, single-center, retrospective review of children admitted between January 1, 2012 to August 30, 2018 with a diagnosis of severe TBI who received HTS. Results Forty-five children (age 9.3 ± 5.8 yr; 60% male) met inclusion criteria. One-hundred eighty-nine equiosmolar bolus doses of HTS were administered to 43 patients (3% HTS, n = 84 doses; 6% HTS, n = 38 doses; 12% HTS, n = 67 doses) for episodes of acute intracranial hypertension (pressure above 20 mmHg). Significant reductions in ICP were observed at 30, 60, and 120 min following HTS boluses with the greatest decrease observed in patients receiving 12%. Thirty-four patients received a continuous infusion of HTS. Higher concentrations of HTS were associated with a more favorable fluid balance (p < .001), fewer episodes of pulmonary edema (p = .003), and higher intake of protein and energy (p < .001). Conclusions Equiosmolar bolus doses of concentrated HTS were associated with significant reductions in ICP. Benefits of higher concentrations of continuous HTS may include improved fluid balance, less pulmonary edema, and greater amounts of protein and energy intake.

Oral Hypertonic Saline Is Effective in Reversing Acute Mild-to-Moderate Symptomatic Exercise-Associated Hyponatremia.

To determine whether oral administration of 3% hypertonic saline (HTS) is as efficacious as intravenous (IV) 3% saline in reversing symptoms of mild-to-moderate symptomatic exercise-associated hyponatremia (EAH) in athletes during and after a long-distance triathlon. Noninferiority, open-label, parallel-group, randomized control trial to IV or oral HTS. We used permuted block randomization with sealed envelopes, containing the word either "oral" or "IV." Annual long-distance triathlon (3.8-km swim, 180-km bike, and 42-km run) at Mont-Tremblant, Quebec, Canada. Twenty race finishers with mild to moderately symptomatic EAH. Age, sex, race finish time, and 9 clinical symptoms. Time from treatment to discharge. We successfully randomized 20 participants to receive either an oral (n = 11) or IV (n = 9) bolus of HTS. We performed venipuncture to measure serum sodium (Na) at presentation to the medical clinic and at time of symptom resolution after the intervention. The average time from treatment to discharge was 75.8 minutes (SD 29.7) for the IV treatment group and 50.3 minutes (SD 26.8) for the oral treatment group (t test, P = 0.02). Serum Na before and after treatment was not significantly different in both groups. There was no difference on presentation between groups in age, sex, or race finish time, both groups presented with an average of 6 symptoms. Oral HTS is effective in reversing symptoms of mild-to-moderate hyponatremia in EAH.

A PUZZLING DIAGNOSIS: UNUSUAL LARYNGEAL CARCINOMA PRESENTING AS PARANEOPLASTIC SYNDROME

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: The Syndrome of Inappropriate Antidiuretic Hormone (SIADH) is one of the most common causes of euvolemic hyponatremia. The most common malignancy associated with SIADH is small cell lung cancer. We present a case of a patient with SIADH secondary to well differentiated squamous cell carcinoma of the vocal cords. CASE PRESENTATION: A 62-year-old Caucasian male with a history of alcohol abuse and 80 pack-year smoking history presented with recurrent hyponatremia. He was initially admitted to the ICU for altered mental status due to hyponatremia of 111 which was thought to be a combination of beer potomania/SIADH/low solute intake. He required hypertonic saline boluses twice and a one dose of DDAVP to prevent overcorrection, along with fluid restriction with an improvement of Na to 132. (Image 1) Chest CT was obtained that did not reveal any malignancy. He was discharged with fluid restriction and follow up with his PCP. At his follow up, he was found to have again developed severe hyponatremia of 112. He was admitted again to the ICU for appropriate normalization of sodium, required isotonic saline and then fluid restriction. SIADH was confirmed by low Serum Osmolality at 245mosm/kg, high Urine osmolality of 502mosm/kg, Urine sodium of 41mEq/l,and normal serum Potassium of 4.3mEq/l along with low serum uric acid of 3.4mg/dl. Upon review of the CT chest with the radiologist he had some density on his left aryepiglottic fold. Upon closer discussion with him, he endorsed progressive hoarseness for the past year to the point of losing his voice. He also lost about 20 pounds over the last year, with a 10-pound weight loss over the past month. CT neck with IV contrast showed a 4.5cm laryngeal mass (Image 2) and direct laryngoscopy and microscopic laryngoscopy with biopsy of the tumor on the left vocal cord with multiple biopsies taken of the terminal vocal cords finally revealed squamous cell carcinoma. He is scheduled to follow up with oncology, ENT and radiation oncology after a PET scan for tumor staging to decide on further treatment with concurrent chemotherapy and radiation. DISCUSSION: There is a possible relationship between the tumor mass burden and the severity of the hyponatremia. This has been shown in another laryngeal carcinoma but was not seen with recurrence of the tumor.[1] The mechanisms leading to the associated hyponatremia could have been related to tumor ADH productions or other factors yet unknown.[2] CONCLUSIONS: SIADH is well known to occur with squamous cell lung cancer. Other types of squamous cell carcinomas are known to cause SIADH as a paraneoplastic syndrome, particularly squamous cell carcinoma of the tongue.[3] It has not been well documented to be from squamous cell carcinoma of vocal cords. Reference #1: Talmi YP, Hoffman HT, McCabe BF (1992) Syndrome of inappropriate secretion of arginine vasopressin in patients with cancer of the head and neck. Ann Otol Rhinol Laryngol 101:946-949 Reference #2: Roth Y, Lightman SL, Kronenberg J. (1994). Hyponatremia associated with laryngeal squamous cell carcinoma. Eur Arch Otorhinolaryngol 251: 183-185 Reference #3: Zohar Y, Talmi YP, Finkelstein Y, Nobel M, Gafter U (1991) Syndrome of inappropriate antidiuretic hormone secretion in cancer of the head and neck. Ann Otol Rhinol Laryngol 100:341-344 DISCLOSURES: No relevant relationships by Sofia Adamidi, source=Web Response no disclosure on file for Steven Lamontagne; No relevant relationships by Preeyanka Sundar, source=Web Response

Boluses of Hypertonic Saline Resulted in More-Rapid Correction in Symptomatic Hyponatremia

Acute symptomatic hyponatremia is a medical emergency that requires rapid intervention. Although serum sodium levels must be increased acutely to avoid

23.4% Hypertonic Saline and Intracranial Pressure in Severe Traumatic Brain Injury Among Children: A 10-Year Retrospective Analysis.

To explore the effect of 23.4% hypertonic saline for management of elevated intracranial pressure in children admitted to our institution for severe traumatic brain injury. Single-center, retrospective medical chart analysis. A PICU at a level 1 pediatric trauma center in the United States. Children admitted for severe traumatic brain injury from 2006 to 2016 who received 23.4% hypertonic saline and whose intracranial pressures were measured within 5 hours of receiving 23.4% hypertonic saline. None. Over the 10-year period, 1,587 children were admitted for traumatic brain injury, 155 of whom were deemed severe per this study's criteria. Forty of these children received at least one dose of hypertonic saline, but 14 were excluded for insufficient intracranial pressure data. Among the remaining 26 children, one hundred one 23.4% hypertonic saline boluses were used in the analysis. Use of 23.4% hypertonic saline was associated with a decrease in intracranial pressure of approximately 7 mm Hg at both within 1 hour after the bolus (p < 0.01) and 4 hours after the bolus (p < 0.01) when compared with the intracranial pressure measured within 1 hour before the hypertonic saline bolus. These effects remained significant after adjusting for Functional Status Scale score and CT Marshall scores. There was no statistically significant association between adjunctive therapies, such as antiepileptics and analgesics, and changes in intracranial pressure. There was no laboratory evidence of hyperkalemia or renal injury after use of 23.4% hypertonic saline. Across all hospitalizations, 65% of the study population demonstrated an abnormally elevated creatinine at least once, but only three episodes of acute kidney injury occurred in total, all before hypertonic saline administration. Eight of the 26 children in this analysis died during their hospitalization. The Functional Status Scale scores ranged from 6 to 26 with a mean of 12.2 and SD of 5.7. Use of 23.4% hypertonic saline with children admitted for severe traumatic brain injury is associated with a statistically significant decrease in intracranial pressure within 1 hour of use.

Bolus therapy with 3% hypertonic saline or 0.9% saline in emergency department patients with suspected sepsis: A pilot randomised controlled trial

Objective and designHypertonic saline administered during fluid resuscitation may mitigate endothelial glycocalyx (EG) shedding and inflammation. The objective of this pilot randomised controlled trial was to measure the effect of hypertonic saline, compared to isotonic saline, on biomarkers of EG shedding and inflammation in emergency department patients with suspected sepsis. MethodsPatients received either 5 mL/kg of 3% saline (hypertonic group, n = 34) or 10 mL/kg of 0.9% saline (isotonic group, n = 31). Change in serum biomarker concentrations of syndecan-1, hyaluronan, intercellular adhesion molecule-1, vascular cell adhesion molecule-1, interleukin-6, -8, -10, interferon-γ, neutrophil gelatinase-associated lipocalin and resistin were compared from baseline (T0) to after fluid (T1), 3 h (T3) and 12–24 h (T24) later, as was serum osmolality, using linear mixed effects models. ResultsThe hypertonic group had significantly increased mean serum osmolality compared to the isotonic group at T1 (P < .001) and T3 (P = .004). Minor differences were found in some biomarker outcomes, including a decreased fold-change in syndecan-1 at T1 (P = .012) and in interleukin-10 at T24 (P = .006) in the isotonic group, compared to the hypertonic group. ConclusionsAlthough a single bolus of hypertonic saline increased serum osmolality, it did not reduce biomarkers of EG shedding or inflammation, compared to patients that received isotonic saline. Trial registrationANZCTR.org.au, ACTRN12611001021965, Registered on 23rd September 2011.

Detection of thoracic vascular structures by electrical impedance tomography: a systematic assessment of prominence peak analysis of impedance changes

Objective: Electrical impedance tomography (EIT) is a non-invasive and radiation-free bedside monitoring technology, primarily used to monitor lung function. First experimental data shows that the descending aorta can be detected at different thoracic heights and might allow the assessment of central hemodynamics, i.e. stroke volume and pulse transit time. Approach: First, the feasibility of localizing small non-conductive objects within a saline phantom model was evaluated. Second, this result was utilized for the detection of the aorta by EIT in ten anesthetized pigs with comparison to thoracic computer tomography (CT). Two EIT belts were placed at different thoracic positions and a bolus of hypertonic saline (10 ml, 20%) was administered into the ascending aorta while EIT data were recorded. EIT images were reconstructed using the GREIT model, based on the individual’s thoracic contours. The resulting EIT images were analyzed pixel by pixel to identify the aortic pixel, in which the bolus caused the highest transient impedance peak in time. Main results: In the phantom, small objects could be located at each position with a maximal deviation of 0.71 cm. In vivo, no significant differences between the aorta position measured by EIT and the anatomical aorta location were obtained for both measurement planes if the search was restricted to the dorsal thoracic region of interest (ROIs). Significance: It is possible to detect the descending aorta at different thoracic levels by EIT using an intra-aortic bolus of hypertonic saline. No significant differences in the position of the descending aorta on EIT images compared to CT images were obtained for both EIT belts.