Three-percent saline administration during pediatric critical care transport

Prehospital Hypertonic Saline Administration After Severe Traumatic Brain Injury

A 25-year old male paient was critically injuried in a high speed motor vehicle collision over an hour from the nearest trauma center. Paramedics diagnosed the patient with a traumatic brain injury and increasing intracranial pressure and transported the patient to a predesignated landing zone for helicopter intercept. During transport paramedics initiated a severe traumatic brain injury protocol which included the adminisration of 3% hypertonic saline. The flight crew continued 3% hypertonic saline managment which was later transferred to the receiving trauma team. Upon trauma center arrival the patient was diagnosed with a skull fracture and subdural hematoma. The patient was transitioned to a 3% hypertonic saline infusion for the next 24 h. The need for integrating systems of care is particularly important when managing patients with severe traumatic brain injury. This case report describes a patient with a severe TBI who received prehospital 3% hypertonic saline based on an integrated protocol developed between multiple prehosptial systems and a tertiary care trauma center. Severe traumatic brain injuries (TBIs) are a potentially catastrophic event, and morbidity can rise precipitously without early interventions to prevent hypoxia and hypotension and control for rising intracranial pressure. In recent years, hypertonic saline (HTS) has shown efficacy in lowering intracranial pressures for patients experiencing TBIs, the leading cause of death and disability among children and young adults in the United States.¹ Integrating care between health care providers across the acute care continuum, from prehospital systems to discharge, is paramount in providing the best patient outcomes possible, especially in health care system expansions such as air medical transport. The need for integrating systems of care is particularly important when managing patients with severe TBI. Statewide prehospital care protocols vary greatly; 78% provide ventilation guidance, 77.3% have targeted end-tidal carbon dioxide levels below < 35 mm Hg, and only 1 (of 38 reviewed) includes HTS (3%).² One barrier to consistency in protocol development is the available literature. One trial demonstrated that a prehospital bolus of 7.5% HTS in severe TBI did not improve mortality.³ However, the Brain Foundation guidelines continue to recommend the prehospital use of hyperosmolar therapy for patients with severe TBI and evidence of impending herniation.⁴ Hyperosmolar therapy is also recommended as an inpatient strategy for lowering increased intracranial pressure (ICP).⁴ One reason for this apparent disconnect is because the ideal timing of HTS administration and its concentration have not been determined.⁴ A meta-analysis previously determined no one prehospital fluid is superior to another in improving the outcomes of patients with severe TBI.⁵ However, none of the reviewed research investigated the continued use of HTS across an integrated system of care. This case report describes a patient with a severe TBI who received 3% HTS initiated in the prehospital setting with the infusion continued upon arrival at the trauma center using a system-wide integrated protocol.

Peripheral IV Administration of Hypertonic Saline: Single-Center Retrospective PICU Study

OBJECTIVES

To determine the frequency and characteristics of complications of peripherally administered hypertonic saline (HTS) through assessment of infiltration and extravasation.

DESIGN

Retrospective cross-sectional study.

SETTING

Freestanding tertiary care pediatric hospital.

PATIENTS

Children who received HTS through a peripheral IV catheter (PIVC).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We conducted a single-center retrospective review from January 2012 to 2019. A total of 526 patients with 1,020 unique administrations of HTS through a PIVC met inclusion criteria. The primary endpoint was PIVC failure due to infiltration or extravasation. The indication for the administration of HTS infusion was collected. Catheter data was captured, including the setting of catheter placement, anatomical location on the patient, gauge size, length of time from catheter insertion to HTS infusion, in situ duration of catheter lifespan, and removal rationale. The administration data for HTS was reviewed and included volume of administration, bolus versus continuous infusion, infusion rate, infusion duration, and vesicant medications administered through the PIVC. There were 843 bolus infusions of HTS and 172 continuous infusions. Of the bolus administrations, there were eight infiltrations (0.9%). The continuous infusion group had 13 infiltrations (7.6%). There were no extravasations in either group, and no patients required medical therapy or intervention by the wound care or plastic surgery teams. There was no significant morbidity attributed to HTS administration in either group.

CONCLUSIONS

HTS administered through a PIVC infrequently infiltrates in critically ill pediatric patients. The infiltration rate was low when HTS is administered as a bolus but higher when given as a continuous infusion. However, no patient suffered an extravasation injury or long-term morbidity from any infiltration.

A Survey of Hospital Pharmacy Guidelines for the Administration of 3% Sodium Chloride in Children

Three percent sodium chloride (3% NaCl) is the treatment of choice for symptomatic hyponatremia. A barrier to the use of 3% NaCl is the perceived risk of both local infusion reactions and neurologic complications from overcorrection. We examine whether children’s hospital pharmacies have policies or practice guidelines for the administration of 3% NaCl and whether these pharmacies have restrictions on the administration of 3% NaCl in terms of rate, route, volume and setting. An Internet survey was distributed to the pharmacy directors of 43 children’s hospitals participating in the Children’s Hospital Association (CHA) network. The response rate was 65% (28/43). Ninety-three percent (26/28) of pharmacy directors reported a restriction for the administration of 3% NaCl, with 57% restricting its use through a peripheral vein or in a non-intensive care unit setting, 68% restricting the rate of administration and 54% restricting the volume of administration. Seventy-one percent (20/28) reported having written policy or practice guidelines. Only 32% of hospital pharmacies allowed 3% NaCl to be administered through a peripheral IV in a non-intensive care unit setting. The majority of children’s hospital pharmacies have restrictions on the administration of 3% NaCl. These restrictions could prevent the timely administration of 3% NaCl in children with symptomatic hyponatremia.

An exploratory assessment of the management of pediatric traumatic brain injury in three centers in Africa

PURPOSE

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). Hospital care practices of pediatric TBI patients in LMICs are unknown. Our objective was to report on hospital management and outcomes of children with TBI in three centers in LMICs.

METHODS

We completed a secondary analysis of a prospective observational study in children (<18 years) over a 4-week period. Outcome was determined by Pediatric Cerebral Performance Category (PCPC) score; an unfavorable score was defined as PCPC > 2 or an increase of two points from baseline. Data were compared using Chi-square and Wilcoxon rank sum tests.

RESULTS

Fifty-six children presented with TBI (age 0-17 y), most commonly due to falls (43%, n = 24). Emergency department Glasgow Coma Scale scores were ≤ 8 in 21% (n = 12). Head computed tomography was performed in 79% (n = 44) of patients. Forty (71%) children were admitted to the hospital, 25 (63%) of whom were treated for suspected intracranial hypertension. Intracranial pressure monitoring was unavailable. Five (9%, n = 5) children died and 10 (28%, n = 36) inpatient survivors had a newly diagnosed unfavorable outcome on discharge.

CONCLUSION

Inpatient management and monitoring capability of pediatric TBI patients in 3 LMIC-based tertiary hospitals was varied. Results support the need for prospective studies to inform development of evidence-based TBI management guidelines tailored to the unique needs and resources in LMICs.

Lidocaine coinfusion alleviates vascular pain induced by hypertonic saline infusion: a randomized, placebo-controlled trial

Background

Hypertonic saline solution has been frequently utilized in clinical practice. However, due to the nonphysiological osmolality, hypertonic saline infusion usually induces local vascular pain. We conducted this study to evaluate the effect of lidocaine coinfusion for alleviating vascular pain induced by hypertonic saline.

Methods

One hundred and six patients undergoing hypertonic saline volume preloading prior to spinal anesthesia were randomly allocated to two groups of 53 each. Group L received a 1 mg/kg lidocaine bolus followed by infusion of 2 mg/kg/h through the same IV line during hypertonic saline infusion; Group C received a bolus and infusion of normal saline of equivalent volume. Visual analogue scale (VAS) scores of vascular pain were recorded every 4 min.

Results

The vascular pain severity in Group L was significantly lower than that in Group C for each time slot (P < 0.05). The overall incidence of vascular pain during hypertonic saline infusion in Group L was 48.0%, which was significantly lower than the incidence (79.6%) in Group C (P < 0.05).

Conclusion

Lidocaine coinfusion could effectively alleviate vascular pain induced by hypertonic saline infusion.

Trial registration

Chinese Clinical Trial Registry, number: ChiCTR1900023753. Registered on 10 June 2019.

Administration of 3% Sodium Chloride Through Peripheral Intravenous Access: Development and Implementation of a Protocol for Clinical Practice

BACKGROUND

Patients with traumatic brain injury, cerebral edema, and severe hyponatremia require rapid augmentation of serum sodium levels. Three percent sodium chloride is commonly used to normalize or augment serum sodium level, yet there are limited data available concerning the most appropriate route of administration. Traditionally, 3% sodium chloride is administered through a central venous catheter (CVC) due to the attributed theoretical risk of phlebitis and extravasation injuries when hyperosmolar solution is administered peripherally. CVCs are associated with numerous complications, including arterial puncture, pneumothorax, infection, thrombosis, and air embolus. Peripherally infused 3% sodium chloride may bypass these concerns.

AIMS

To explore the evidence for peripherally infused 3% sodium chloride and to implement the findings.

METHODS

The Iowa Model of Evidence-Based Practice (EBP) was used to guide the project. A multidisciplinary team was established, and they developed an evidence-based protocol for the administration of 3% sodium chloride using peripheral intravenous catheters (PIVs), identified potential barriers to implementation, and developed targeted education to implement this practice change in a large academic medical center.

RESULTS

Of the 103 patients in this project, only three (2.9%) identified adverse events. Two were associated with continuous infusions, and one was associated with a bolus infusion.

LINKING ACTION TO EVIDENCE

This is the first study to describe a multidisciplinary protocol development and implementation process for the administration of 3% sodium chloride peripherally. Utilizing a multidisciplinary team is critical to the success of an EBP project. Implementing an evidence-based PIV protocol with stringent monitoring criteria for the administration of 3% sodium chloride has the potential to reduce adverse events related to CVC injury.

Effect of hypertonic saline in the management of elevated intracranial pressure in children with cerebral edema: A systematic review and meta-analysis

Objective:

To determine the hypertonic saline efficacy in children with cerebral edema and raised intracranial pressure.

Method:

Studies assessing the efficacy and safety of hypertonic saline in children with cerebral edema and elevated intracranial pressure were identified using Medline, Web of Science, Scopus, and Google Scholar databases. Two reviewers independently assessed papers for inclusion. The primary outcome was a reduction of elevated intracranial pressure by the administration of hypertonic saline.

Results:

We initially evaluated 1595 potentially relevant articles, and only 7 studies met the eligibility criteria for the final analysis. Out of the seven studies, three of them were randomized controlled trials. Three of the studies found that hypertonic saline significantly reduced elevated intracranial pressure compared to control. One study reported a resolution of the comatose state as a measure of reduced intracranial pressure. It also found a significantly higher resolution of coma in the hypertonic saline group rather than the control. Three studies reported that the reduction of intracranial pressure was comparable between the groups. The random-effects model using pooled estimates from four studies showed no difference in hypertonic saline and conventional therapy mortality outcomes. Hypertonic saline was administered as bolus-only therapy at a rate of 1–10 mL/kg/dose over 5 min to 2 h and or bolus followed by infusion therapy (0.5–2 mL/kg/h). One study reported a twofold faster resolution of high intracranial pressure following hypertonic saline administration compared to controls. The re-dosing schedule varied greatly in all included studies. However, three studies reported adverse events but not methodically, and there were no reports on neurological sequelae.

Conclusion:

Hypertonic saline appears to reduce intracranial pressure in children with cerebral edema. However, we cannot draw a firm conclusion regarding the safest dose regimens of hypertonic saline, including the safe and effective therapeutic hypernatremia threshold in the management of raised intracranial pressure with cerebral edema. Future clinical trials should focus on the appropriate concentration, dose, duration, mode of administration, and adverse effects of hypertonic saline to standardize the treatment.

The Evaluation of Trauma Care: The Comparison of 2 High-Level Pediatric Emergency Departments in the United States and Turkey

OBJECTIVE

The purpose of the study is to compare the outcomes of pediatric trauma patients with motor vehicle crashes (MVCs) and motor vehicle versus pedestrian crashes (MPCs) at a level 1 pediatric trauma center in the United States and a pediatric trauma center in Turkey.

METHODS

The medical records of all pediatric MVC and MPC subjects presenting to the emergency departments (EDs) of a level 3 hospital in Turkey (Izmir Tepecik Training and Research Hospital [ITTRH]) and a level 1 pediatric trauma center in the United States (Children's Medical Center Dallas [CMCD]) over a 1-year period were reviewed. Data that were collected include patient demographics, prehospital report (mechanism of injury, mode of transportation), injury severity score (ISS), abbreviated injury scale score, Glasgow Coma Scale score, ED length of stay, ED interventions, ED and hospital disposition, and mortality. Patients with moderate (ISS, 5-15) and severe (ISS, >15) trauma scores were included in the study.

RESULTS

One hundred six patient charts from the ITTRH and 125 patient charts from the CMCD with moderate and severe ISS due to MVCs and MPCs were reviewed. Most of the patients were pedestrians (86%) in the ITTRH group and passengers (60%) in the CMCD group. The percentage of patients transferred by ambulance (ground or air) to the CMCD and the ITTRH was 97.9% and 85%, respectively. Fifteen percent of ITTRH patients and 2.1% of CMCD patients arrived by private vehicle. Emergency department arrival ISS and Glasgow Coma Scale were similar between the 2 hospitals (P > 0.05). The overall mortality rate in the study population was 8.8% (11/125) at the CMCD and 4.7% (5/106) at the ITTRH. (P = 0.223). Blood product utilization was significantly higher in the CMCD group compared with the ITTRH group (P = 0.005). The use of hypertonic saline/mannitol/hyperventilation in patients with significant head trauma and increased intracranial pressure was higher in the ITTRH group (P = 0.000).

CONCLUSIONS

This is the first study that compared pediatric trauma care and outcome at a level 1 pediatric trauma center in the United States and a pediatric hospital in Turkey. Our findings highlight the opportunities to improve pediatric trauma care in Turkey. Specifically, there is a need for national trauma registries, enhanced trauma education, and standardized trauma patient care protocols. In addition, efforts should be directed toward improving prehospital care through better integration within the health care system and physician participation in educating prehospital providers. Data and organized trauma care will be instrumental in system-wide improvement and developing appropriate injury-prevention strategies.

Standardized Volume Dosing Protocol of 23.4% Hypertonic Saline for Pediatric Critical Care: Initial Experience

Background: Standardized volume dosing of 23.4% hypertonic saline (HTS) exists for adults, but the concentration, dosing and administration of HTS in pediatrics is variable. With emerging pediatric experience of 23.4% HTS, a standard volume dose approach may be helpful. Objective: To describe initial experience with a standardized 23.4% HTS weight-based volume dosing protocol of 10, 20, or 30 mL in the pediatric intensive care unit. Methods: Standard volume doses of 23.4% HTS were developed from weight dosing equivalents of 3% HTS. Pre and post sodium and intracranial pressure (ICP) measurements were compared with paired t-test or Wilcoxon rank-sum test. The site of administration and complications were noted. Results: A total of 16 pediatric patients received 37 doses of 23.4% HTS, with the smallest patient weighing 11 kg. For protocol compliance, 17 doses (46%) followed recommended dosing, 19 were less volume than recommended (51%), and 1 dose (3%) was more than recommended. Mean increase in sodium was 3.5 mEq/L (95% CI = 2-5 mEq/L); P < 0.0001. The median decrease in ICP was 10.5 mm Hg (interquartile range [IQR] 8.3-19.5) for a 37% (IQR 25%-64%) reduction. Most doses were administered through central venous access, although peripheral intravenous administrations occurred in 4 patients without complication. Conclusion and Relevance: Three standard-volume dose options of 23.4% HTS based on weight increases sodium and reduces ICP in pediatric patients. Standard-volume doses may simplify weight-based dosing, storage and administration for pediatric emergencies, although the optimum dose, and safety of 23.4% HTS in children remains unknown.

Misconceptions and Barriers to the Use of Hypertonic Saline to Treat Hyponatremic Encephalopathy

Hyponatremic encephalopathy is a potentially life-threatening condition with a high associated morbidity and mortality. It can be difficult to diagnose as the presenting symptoms can be non-specific and do not always correlate with the degree of hyponatremia. It can rapidly progress leading to death from transtentorial herniation. Hypertonic saline is the recommended treatment for hyponatremic encephalopathy, whether acute or chronic, yet it is infrequently used. We believe that the main barriers to its use is the perception that hypertonic saline is associated with a significant risk for cerebral demyelination, that it can't be administered through a peripheral IV and that it requires monitoring in the ICU. Two illustrative cases are presented followed by a discussion of how intermittent bolus's of 100−150 ml of 3% NaCl in rapid succession to acutely increase the plasma sodium by 4−6 mEq/L is a safe and effective way to treat hyponatremic encephalopathy, that can be administered through a peripheral IV in a non-ICU setting.

Safety of Peripheral Line Administration of 3% Hypertonic Saline and Mannitol in the Emergency Department

BACKGROUND

Hypertonic saline (HTS) and mannitol are frequently utilized in the emergency department (ED) to manage elevations in intracranial pressure (ICP).

OBJECTIVE

The objective of this study was to compare the incidence of extravasation injury when HTS or mannitol was administered via peripheral i.v. line (PIV).

METHODS

This retrospective cohort study evaluated adult and pediatric patients given either 3% HTS or mannitol via PIV while in the ED. The primary outcome was extravasation incidence.

RESULTS

One hundred and ninety-two patients were included, of which 85 (44%) received HTS and 107 (56%) received mannitol. Patients who received HTS were younger (27.5 ± 24.3 years vs. 53.9 ± 22.3 years; p < 0.001); 55.3% of patients given HTS received it for traumatic brain injury (TBI) versus 38.3% of patients given mannitol (p = 0.021); and 44.9% of patients given mannitol received it for intracerebral hemorrhage versus 21.2% of patients given HTS (p = 0.001). There was no incidence of extravasation in either group. Patients who received HTS had lower ICP measurement 24 h post admission (2.107 ± 5.5 mm Hg vs. 4.236 ± 8.1 mm Hg; p = 0.047) and higher Glasgow Coma Scale (GCS) score upon discharge (GCS 14; interquartile range [IQR] 3-15 vs. GCS 3; IQR 3-14.2; p = 0.004). In-hospital mortality was higher in the mannitol group (54.7% vs. 32.9%; p = 0.003). Duration of mechanical ventilation was shorter in those patients who received HTS (1 day; IQR 0-56 days vs. 2 days; IQR 0-56 days; p = 0.023).

CONCLUSIONS

There were no incidences of extravasation among patients given 3% HTS or mannitol. Clinicians should reconsider recommendations to restrict HTS or mannitol to central lines.

Association between continuous peripheral i.v. infusion of 3% sodium chloride injection and phlebitis in adults

PURPOSE

One institution's experience with use of peripheral i.v. (PIV) catheters for prolonged infusions of 3% sodium chloride injection at rates up to 100 mL/hr is described.

METHODS

A prospective, observational, 13-month quality assurance project was conducted at an academic medical center to evaluate frequencies of patient and catheter phlebitis among adult inpatients who received both an infusion of 3% sodium chloride injection for a period of ≥4 hours through a dedicated PIV catheter and infusions of routine-care solutions (RCSs) through separate PIV catheters during the same hospital stay.

RESULTS

Sixty patients received PIV infusions through a total of 291 catheters during the study period. The majority of patients (78%) received infusions of 3% sodium chloride injection for intracranial hypertension, with 30% receiving such infusions in the intensive care unit. Phlebitis occurred in 28 patients (47%) during infusions of 3% sodium chloride and 26 patients (43%) during RCS infusions (p = 0.19). Catheter phlebitis occurred in 73 catheters (25%), with no significant difference in the frequencies of catheter phlebitis with infusion of 3% sodium chloride versus RCSs (30% [32 of 106 catheters]) versus 22% [41 of 185 catheters]), p = 0.16).

CONCLUSION

Patient and catheter phlebitis rates were not significantly different with infusions of 3% sodium chloride injection versus RCSs, suggesting that an osmolarity cutoff value of 900 mOsm/L for peripheral infusions of hypertonic saline solutions may not be warranted.

Incidence of Adverse Events During Peripheral Administration of Sodium Chloride 3

PURPOSE

Traditionally, sodium chloride 3% has been administered via a central venous line (CVL) because of the perceived risk of infiltration and tissue injury due to its high osmolarity. In clinical practice, sodium chloride 3% is commonly administered through peripheral venous catheters (PVCs) given the necessity of timely administration. However, there is no published data on the safety of administering sodium chloride 3% through PVCs in the adult population. The objective of this study was to evaluate the safety of peripheral venous administration of sodium chloride 3%.

MATERIALS AND METHODS

A retrospective review was conducted in patients who received sodium chloride 3% in the intensive care unit (ICU). Patients were excluded if they had a CVL for the entire duration of the infusion or younger than 18 years at the time of administration. Baseline patient and infusion characteristics were collected. Infusion-related adverse events (IRAEs) were recorded, graded, and interventions required were noted.

RESULTS

A total of 66 patients were included in the analysis. The most common indication was hyponatremia and majority of the patients were managed in the neurosurgical ICU. The most common risk factor for IRAEs was the presence of altered mental status. Four patients experienced an IRAE at an event rate of 6.1%. Patients who experienced an IRAE ranged from 38 to 82 years old. The IRAEs were grade 1 in severity, managed conservatively with removal of the PVC, and 2 of the 4 patients had their infusions restarted peripherally. The time to initial IRAE ranged from 2 to 94 hours. For the entire cohort, hospital and ICU length of stay were 8 and 4 days, respectively.

CONCLUSIONS

The rate of IRAEs related to the infusion of sodium chloride 3% through PVCs appears to be similar to those reported with other hyperosmotic agents and could be considered for patients who need time-sensitive therapy.

Special considerations in infants and children

Head injury in children is one of the most common causes of death and disability in the US and, increasingly, worldwide. This chapter reviews the causes, patterns, pathophysiology, and treatment of head injury in children across the age spectrum, and compares pediatric head injury to that in adults. Classification of head injury in children can be organized according to severity, pathoanatomic type, or mechanism. Response to injury and repair mechanisms appear to vary at different ages, and these may influence optimal treatment; however, much work is still needed before investigation leads to clearly effective clinical interventions. This is true both for the more severe injuries as well as those at the milder end of the injury spectrum, the latter of which have received increasing attention. In this chapter, neuroassessment tools for each age, newer imaging modalities including magnetic resonance imaging (MRI), and specific pediatric management issues, including intracranial pressure (ICP) monitoring and seizure prophylaxis, are reviewed. Finally, specific head injury patterns and functional outcomes relevant to pediatric patients are discussed. While head injury is common, the number of head-injured children is significantly smaller than the corresponding adult head-injured population. When divided further by specific ages, injury types, and other sources of heterogeneity, properly powered clinical research is likely to require large data sets that will allow for stratification across variables, including age. While much has been learned in the past several decades, further study will be required to determine the best management practices for optimizing recovery in individual pediatric patients. This approach is likely to depend on collaborative international head injury databases that will allow researchers to better understand the nuanced evolution of different types of head injury in patients at each age, and the pathophysiologic, treatment-related, and genetic factors that influence recovery.

Evaluation of extremity tissue and bone injury after intraosseous hypertonic saline infusion in proximal tibia and proximal humerus in adult swine

BACKGROUND

Hypertonic saline (HTS) has been reported as a treatment for sever traumatic brain injury and hemorrhagic shock and current clinical guidelines recommend it. Intraosseous (IO) infusion is often needed in the pre-hospital and combat settings to administer life-saving treatments. However, the safety of IO HTS infusion is not clear. The aim of our study was to evaluate the clinical and histological outcome of HTS IO infusion into the extremity of a large animal model.

METHODS

We conducted a randomized comparative study of adult pigs that were infused intraosseously with one of the following solutions: 7.5% HTS, 3% HTS or normal 0.9% isotonic saline. The animals were observed daily for infection, necrosis and gait (5 point Tarlov score) up to 5 days. Five days after infusion, necropsy and histological analysis was performed using a validated scale of tissue necrosis.

RESULTS

The mean Tarlov gait scores were similar in all arms and all animals showed a score of 4 (normal ambulation) by day 5. During the 5 day observation period, there were no signs of infection or tissue abnormalities. Histological examinations showed no indication of necrosis, or abnormal bone and muscle healing (p < 0.05).

CONCLUSION

We observed regular tissue morphology and normal gait scores over the 5 day observation period. There was an absence of gross tissue necrosis and microscopic ischemia post IO HTS infusion in this swine model. This data confirms the clinical safety of IO HTS infusion and highlights its use as an alternative lifesaving treatment.

New trends in hyperosmolar therapy?

PURPOSE OF REVIEW

To discuss trends in the use of osmotic therapy.

RECENT FINDINGS

Use of osmotic therapy has evolved from bolus administration of mannitol to routine use of hypertonic saline as a bolus as well as in continuous infusions to creating a sustained hyperosmolar state.In a survey of neurointensivists 55% favored hypertonic saline over mannitol. Retrospective studies suggest better intracranial pressure (ICP) control with hypertonic saline. Whereas a prospective study in adults with head injury compared alternating doses of mannitol and hypertonic saline and found no difference in change in ICP control or outcome, two meta-analyses, which did not include this study, favored hypertonic saline for ICP control (although the absolute difference of 2 mmHg is of little clinical value) with no difference in outcome.Hypertonic saline has also been administered by infusions to creating a sustained stable hyperosmolar state. Two studies, using historical controls, suggested benefit of hypertonic saline infusions. In a prospective, randomized study, in children with severe head injury Lactated Ringer's solution was compared to hypertonic saline. Although ICP control was similar, the hypertonic saline group required fewer other interventions.

SUMMARY

The existing data do not support favoring boluses of hypertonic saline over mannitol in terms of ICP control, let alone outcome. The rationale for continuous infusions to create a sustained hyperosmolar state is open to discussion and use of this approach should be curtailed pending further research.