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

Adverse Effects of HTS

Nurses who are administering HTS to patients need to exercise vigilance as they assess for adverse effects. This is especially true because HTS is mainly used during the acute phase of head injury care, when patients are at particular risk for physiologic complications. Some adverse effects have been documented in clinical situations; others are mainly theoretical issues (Suarez, 2004).

The most serious potential complication is central pontine myelinolysis (CPM). CPM has occurred in situations in which serum sodium levels rise quickly (in a matter of minutes). This syndrome, which is characterized by a rapid and irreversible demyelination of the pons, is manifested by a decreased level of consciousness and severe quadriparesis. These symptoms are difficult to immediately identify in patients with severe TBI, although the consequences of CPM would be devastating (Doyle et al., 2001). CPM has not been reported in human trials using HTS for TBI.

Avoiding CPM is of utmost concern. Careful monitoring is necessary to avoid rapid rises in serum sodium. Gradual changes in serum sodium, no greater than 10–20 mEq/L per day, are recommended. As another precaution, HTS should not be started if serum sodium levels are lower than normal. Patients with hyponatremia should be treated with normal saline until their serum sodium levels normalize; then HTS can be started (Qureshi & Suarez, 2000).

Acute renal insufficiency is a primary concern with the use of hyperosmolar therapies for TBI. Renal problems can be minimized by maintaining euvolemia. Central venous pressures, pulmonary artery monitoring, or both, are used if needed. Other interventions include carefully monitoring laboratory values and contacting a renal specialist if any signs of renal insufficiency appear (Doyle et al., 2001; Qureshi & Suarez, 2000).

Because HTS therapy involves drawing fluid from tissues into the blood, its use could cause pulmonary or peripheral edema or heart failure. If for some reason the blood became hypotonic to the peripheral or central tissues, fluid would move from the blood to the tissues. This fluid movement could lead to edema of the brain, vital organs, and peripheral tissues. Careful monitoring of laboratory values and fluid status is needed to avoid or minimize these problems (Suarez, 2004).

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