Use of Hypertonic Saline Injection in Trauma

Asad E. Patanwala; Albert Amini; Brian L. Erstad

Disclosures

Am J Health Syst Pharm. 2010;67(22):1920-1928. 

In This Article

Summary and Recommendations

Trials evaluating the use of hypertonic saline solutions for resuscitation after traumatic injury have not shown an overall mortality benefit compared with isotonic fluid administration. The largest trials to date by ROC were terminated by NHLBI due to futility. Given that this is a relatively recent development, the results have not yet been published, but the increase in early mortality found with hypertonic saline is concerning, and hypertonic saline cannot be recommended over 0.9% sodium chloride injection or lactated Ringer's solution at this time. Of note, patients with burns were excluded from the two studies funded by NHLBI, so the effects of hypertonic saline in this patient population need further investigation. Although the use of hypertonic saline for resuscitation is not recommended at this time, a discussion of dosing strategies is important.

Most studies involving patients with hypovolemic shock used a single 250-mL bolus dose of 7.5% hypertonic saline, with or without dextran. The closest concentration that is commercially available is 5% (500 mL), so a single dose of 350–400 mL could be used to provide a similar sodium load. We suggest a maximum dose of 500 mL of 5% hypertonic saline for resuscitation. Higher or repeated doses of hypertonic saline should be questioned due to safety concerns.

All three RCTs that compared hypertonic saline with mannitol for ICP reduction in patients with TBI have shown that hypertonic saline is more effective. However, these were relatively small trials; the largest included only 32 patients. Hypertonic saline shows promise for this indication and can be considered as an alternative to mannitol when a hyperosmolar agent is indicated. The optimal dose, concentration, and infusion strategy (bolus dose versus continuous infusion) have yet to be determined. One retrospective study found a higher mortality rate with the use of continuous infusion hypertonic saline,[63] but this finding requires confirmation in a prospective RCT. We recommend a single i.v. bolus dose of 250 mL of 3% or 5% hypertonic saline for most adults for ICP reduction. If used as a continuous infusion, then an initial dose of 1 mL/kg/hr of 3% hypertonic saline would be acceptable based on the study that used this approach.[63] Irrespective of dosing strategy, we concur with the authors of other reviews that the serum sodium concentrations in adults receiving hypertonic saline should not exceed 155–160 meq/L.[76] –79 Somewhat higher maximum serum sodium concentrations (e.g., 165–170 meq/L) have been suggested for children.[78] Note that serum sodium levels should not be increased by >12 meq/L in 24 hours to minimize the risk for central pontine myelinolysis. Although it is commonly recommended that serum osmolarity should be maintained at <320 mOsm/L, relatively little evidence supports this maximum limit.[76] Limits for serum sodium levels and serum osmolarity only should be exceeded when the potential benefit for additional ICP reduction is thought to outweigh the potential risk of toxicity. It is prudent to monitor serum sodium and osmolarity levels before administering any bolus dose of hypertonic saline. When continuous infusions are used, serum sodium and osmolarity levels should be monitored every 4–6 hours until stable.

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