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Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in pediatric traumatic brain injury.
Crit Care Med. 2000 Apr; 28(4):1144-51.CC

Abstract

OBJECTIVES

To evaluate the effect of prolonged infusion of 3% hypertonic saline (514 mEq/L) and sustained hypernatremia on refractory intracranial hypertension in pediatric traumatic brain injury patients.

DESIGN

A prospective study.

SETTING

A 24-bed Pediatric Intensive Care Unit (Level III) at Children's Hospital.

PATIENTS

We present ten children with increased intracranial pressure (ICP) resistant to conventional therapy (head elevation at 30 degrees, normothermia, sedation, paralysis and analgesia, osmolar therapy with mannitol, loop diuretic, external ventricular drainage in five patients), controlled hyperventilation (Pco2, 28-35 mm Hg), and barbiturate coma. We continuously monitored ICP, cerebral perfusion pressure (CPP), mean arterial pressure, central venous pressure, serum sodium concentrations, serum osmolarity, and serum creatinine.

INTERVENTIONS

A continuous infusion of 3% saline on a sliding scale was used to achieve a target serum sodium level that would maintain ICP <20 mm Hg once the conventional therapy and barbiturate coma as outlined above failed to control intracranial hypertension.

MEASUREMENTS AND MAIN RESULTS

The mean duration of treatment with 3% saline was 7.6 days (range, 4-18 days). The mean highest serum sodium was 170.7 mEq/L (range, 157-187 mEq/L). The mean highest serum osmolarity was 364.8 mosm/L (range, 330-431 mosm/L). The mean highest serum creatinine was 1.31 mg/dL (range, 0.4-5.0 mg/dL). There was a steady increase in serum sodium versus time zero that reached statistical significance at 24, 48, and 72 hrs (p < .01). There was a statistically significant decrease in ICP spike frequency at 6, 12, 24, 48, and 72 hrs (p < .01). There was a statistically significant increase in CPP versus time zero at 6, 12, 24, 48, and 72 hrs (p < .01). There was a statistically significant increase in serum osmolarity versus time zero at 12 hrs (p < .05) and at 24, 48, and 72 hrs (p < .01). Two patients developed acute renal failure and required continuous veno-venous hemodialysis; these were concurrent with an episode of sepsis and multisystem organ dysfunction. Both recovered full renal function with no electrolyte abnormalities at the time of discharge.

CONCLUSION

An increase in serum sodium concentration significantly decreases ICP and increases CPP. Hypertonic saline is an effective agent to increase serum sodium concentrations. Sustained hypernatremia and hyperosmolarity are safely tolerated in pediatric patients with traumatic brain injury. Controlled trials are needed before recommendation of widespread use.

Authors+Show Affiliations

Division of Pediatric Critical Care Medicine, Children's Hospital, San Diego, CA, USA.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article

Language

eng

PubMed ID

10809296

Citation

Khanna, S, et al. "Use of Hypertonic Saline in the Treatment of Severe Refractory Posttraumatic Intracranial Hypertension in Pediatric Traumatic Brain Injury." Critical Care Medicine, vol. 28, no. 4, 2000, pp. 1144-51.
Khanna S, Davis D, Peterson B, et al. Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in pediatric traumatic brain injury. Crit Care Med. 2000;28(4):1144-51.
Khanna, S., Davis, D., Peterson, B., Fisher, B., Tung, H., O'Quigley, J., & Deutsch, R. (2000). Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in pediatric traumatic brain injury. Critical Care Medicine, 28(4), 1144-51.
Khanna S, et al. Use of Hypertonic Saline in the Treatment of Severe Refractory Posttraumatic Intracranial Hypertension in Pediatric Traumatic Brain Injury. Crit Care Med. 2000;28(4):1144-51. PubMed PMID: 10809296.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in pediatric traumatic brain injury. AU - Khanna,S, AU - Davis,D, AU - Peterson,B, AU - Fisher,B, AU - Tung,H, AU - O'Quigley,J, AU - Deutsch,R, PY - 2000/5/16/pubmed PY - 2000/6/8/medline PY - 2000/5/16/entrez SP - 1144 EP - 51 JF - Critical care medicine JO - Crit. Care Med. VL - 28 IS - 4 N2 - OBJECTIVES: To evaluate the effect of prolonged infusion of 3% hypertonic saline (514 mEq/L) and sustained hypernatremia on refractory intracranial hypertension in pediatric traumatic brain injury patients. DESIGN: A prospective study. SETTING: A 24-bed Pediatric Intensive Care Unit (Level III) at Children's Hospital. PATIENTS: We present ten children with increased intracranial pressure (ICP) resistant to conventional therapy (head elevation at 30 degrees, normothermia, sedation, paralysis and analgesia, osmolar therapy with mannitol, loop diuretic, external ventricular drainage in five patients), controlled hyperventilation (Pco2, 28-35 mm Hg), and barbiturate coma. We continuously monitored ICP, cerebral perfusion pressure (CPP), mean arterial pressure, central venous pressure, serum sodium concentrations, serum osmolarity, and serum creatinine. INTERVENTIONS: A continuous infusion of 3% saline on a sliding scale was used to achieve a target serum sodium level that would maintain ICP <20 mm Hg once the conventional therapy and barbiturate coma as outlined above failed to control intracranial hypertension. MEASUREMENTS AND MAIN RESULTS: The mean duration of treatment with 3% saline was 7.6 days (range, 4-18 days). The mean highest serum sodium was 170.7 mEq/L (range, 157-187 mEq/L). The mean highest serum osmolarity was 364.8 mosm/L (range, 330-431 mosm/L). The mean highest serum creatinine was 1.31 mg/dL (range, 0.4-5.0 mg/dL). There was a steady increase in serum sodium versus time zero that reached statistical significance at 24, 48, and 72 hrs (p < .01). There was a statistically significant decrease in ICP spike frequency at 6, 12, 24, 48, and 72 hrs (p < .01). There was a statistically significant increase in CPP versus time zero at 6, 12, 24, 48, and 72 hrs (p < .01). There was a statistically significant increase in serum osmolarity versus time zero at 12 hrs (p < .05) and at 24, 48, and 72 hrs (p < .01). Two patients developed acute renal failure and required continuous veno-venous hemodialysis; these were concurrent with an episode of sepsis and multisystem organ dysfunction. Both recovered full renal function with no electrolyte abnormalities at the time of discharge. CONCLUSION: An increase in serum sodium concentration significantly decreases ICP and increases CPP. Hypertonic saline is an effective agent to increase serum sodium concentrations. Sustained hypernatremia and hyperosmolarity are safely tolerated in pediatric patients with traumatic brain injury. Controlled trials are needed before recommendation of widespread use. SN - 0090-3493 UR - https://www.unboundmedicine.com/medline/citation/10809296/Use_of_hypertonic_saline_in_the_treatment_of_severe_refractory_posttraumatic_intracranial_hypertension_in_pediatric_traumatic_brain_injury_ L2 - https://dx.doi.org/10.1097/00003246-200004000-00038 DB - PRIME DP - Unbound Medicine ER -