Administering Hypertonic Saline to Patients With Severe Traumatic Brain Injury

Diane Schretzman Mortimer; Jon Jancik

Disclosures

J Neurosci Nurs. 2006;38(3):142-146. 

In This Article

Administering HTS by Continuous Infusion

HTS can be administered via continuous infusion for acute head trauma care. The HTS infusion rate can vary from 30 ml per hr to upwards of 150 ml per hr (Qureshi et al., 1998). The rate is adjusted according to serum sodium levels (Khanna et al., 2000). The HTS solution can either supplement or replace the maintenance intravenous solution, depending on the patient's electrolyte levels and fluid requirements (Qureshi et al., 1998). A summary of nursing care for patients receiving continuous HTS infusions follows.

If the NaCl concentration is greater than 2%, HTS must be administered through a central line. It cannot be given peripherally, because HTS in concentrations of 3% or higher can cause local vascular irritation. HTS would also be harmful to local tissues if the intravenous site became infiltrated. The presence of HTS in the tissues of the arm and hand can cause cells of these tissues to become extremely edematous as fluid is pulled in. This dangerous edema can cause tissue damage and even lead to necrosis (Suarez, 2004).

Patients receiving continuous HTS infusions should have their serum sodium levels checked at least every 6 hr. The main objective of continuous HTS therapy is to provide an optimal osmolar gradient while avoiding the dangerous effects of hypernatremia. Maintaining serum sodium levels of 145–155 mmol/L is likely to achieve this goal (Qureshi & Suarez, 2000; Qureshi et al., 1998; Qureshi et al., 1999). Serum sodium levels should be maintained no higher than 155 mmol/L. Higher levels are dangerous. Patients with serum sodium levels higher than 160 mmol/L are at increased risk for treatment-related renal failure, pulmonary edema, and heart failure (Qureshi & Suarez, 2000). If serum sodium levels remain above 160 mmol/L for more than 48 hr, the risk of these problems increases even more. Furthermore, if serum sodium levels climb beyond 160 mmol/L, patients are at risk for seizures (Qureshi et al., 1998).

Serum osmolarity levels should also be monitored. HTS is an osmolar agent, and it directly affects serum osmolarity levels. These levels, which do not change as rapidly as serum sodium levels, should be checked every 12 hr while patients are receiving continuous HTS infusions. The target serum osmolarity is less than 320 mOsmol/L. At higher levels, patients are at increased risk for treatment-related renal failure (Qureshi & Suarez, 2000; Suarez, 2004).

HTS needs to be administered at a carefully controlled rate. Like other critical infusions, HTS should be run on a pump. HTS is not compatible with all medications. In particular, drugs that are only compatible with normal saline are not compatible with HTS. It is important to check with institutional pharmacists before administering other medications though the HTS line. Transfusions of blood or blood products cannot be given through the HTS line. These products must be given with normal saline, because the highly concentrated HTS solution could cause lysis of red blood cells (Qureshi & Suarez, 2000).

Nurses must inform other healthcare team members about HTS administration. For example, if the patient receiving HTS goes to surgery, the nurse has to ensure that the anesthetist carefully monitors the HTS drip and serum sodium levels. In addition, the nurse should communicate goals of the patient's HTS treatment to the various medical teams involved (Johnson & Criddle, 2004; Wright, 1999).

Fluid status must be closely monitored. HTS therapy is associated with fewer renal complications when patients are euvolemic than when patients are hypovolemic. If it occurs, hypovolemia can be treated with intravenous fluids or blood products, depending on the patient's needs (Suarez, 2004). On the other hand, giving HTS may cause some patients to become hypervolemic.

Nurses must carefully observe indicators of fluid status, such as intake and output, patient weight, and available hemodynamic values. Chest X rays should be obtained daily to assess for signs of pulmonary edema (Qureshi & Suarez, 2000).

Nurses need to exercise special caution when administering HTS to older adults via continuous infusion. Normal age-related changes as well as concomitant renal, cardiac, and pulmonary illnesses can put older adults at increased risk for complications of HTS therapy. Older adults may develop treatment-related complications more rapidly than younger adults. Older adults' serum sodium levels and fluid status should be carefully monitored to prevent or minimize these problems (Whitney, Pugh, & Mortimer, 2004).

Nurses administering HTS to children should follow the facility's protocol. HTS has safely and effectively been utilized in children with TBI. It is particularly beneficial in treating refractory increases in ICP in these injured young people (Khanna et al., 2000; Knapp, 2005; Peterson, Khan-na, Fisher, & Marshall, 2000; Simma et al., 1998).

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