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

Resuscitation of Patients with Traumatic Hemorrhage

There have been several randomized controlled trials (RCTs) that have evaluated the use of hypertonic saline for resuscitation of the hypovolemic trauma patient.[25–37] In these studies, patients were randomized to receive a single 250-mL bolus of study fluid (0.9% sodium chloride injection, lactated Ringer's solution, or hypertonic saline solution) in the prehospital setting or in the emergency department. After administration of this bolus dose, resuscitation was continued with standard crystalloids such as 0.9% sodium chloride injection or lactated Ringer's solution. Isotonic crystalloids were compared with 7.5% hypertonic saline[31,33,34,36] or 7.5% hypertonic saline–6% dextran 70.[26–30,32,35] Several of the studies evaluated survival as an endpoint; however, few were adequately powered to show a difference in survival between treatment groups. In the largest of these published RCTs, the authors estimated that 700 patients would be required to show a difference in survival, but only 422 patients were enrolled.[30] Only one study demonstrated a statistically significant survival benefit with the use of 7.5% hypertonic saline–6% dextran 70.[37] In this study, 212 patients with hemorrhagic hypovolemia were randomized to receive a 250-mL bolus dose of 0.9% sodium chloride injection or 7.5% hypertonic saline–6% dextran 70 in the emergency department. Patients in the latter group had a higher 24-hour survival rate (87% versus 72%, p < 0.01) and 30-day survival rate (73% versus 64%, p = 0.02). The patients most likely to benefit from the combination solution were those with an MAP of <70 mm Hg. There is no obvious explanation as to why only this study showed a difference in survival.

In one study, actual survival was greater than predicted survival in patients given hypertonic saline.[34] Trauma patients with systolic blood pressures of <90 mm Hg in the field were given 250 mL of lactated Ringer's solution or 7.5% hypertonic saline with or without dextran. Overall, there was no difference in survival between treatment groups. However, the probability of survival was also estimated using the Trauma and Injury Severity Score method, a standard approach for evaluating the outcome of trauma care.[38] The survival rate among patients treated with 7.5% hypertonic saline was higher than predicted (60% versus 48%, p < 0.001). Also, the subgroup of patients with Glasgow Coma Scale scores of ≤8 had improved survival with 7.5% hypertonic saline compared with lactated Ringer's solution (34% versus 12%, respectively; p < 0.05). In other studies, post hoc subgroup analyses suggested that certain populations were more likely to benefit from hypertonic saline, including patients with TBI, with low MAP, and who require massive transfusion or surgery.[26,32,33,37,39]

A few trials found a modest overall decrease in fluid requirements needed for resuscitation in patients treated with hypertonic saline compared with those receiving isotonic crystalloids.[30,32,36,37,39] However, the time points when fluid requirement were assessed differed among studies and included total fluids provided in the prehospital setting, emergency department, or operating room or 24-hour fluid measurements. None of the studies reported a difference in fluid requirements of >1 L of crystalloids at 24 hours postinjury. One of the theoretical benefits of hypertonic saline, as previously discussed, is a smaller fluid requirement for resuscitation that may lead to fewer complications (e.g., pulmonary edema). However, none of the studies reported a statistically significant difference in postresuscitation complications. A recent Cochrane review concluded that there is no evidence that hypertonic crystalloids are better than isotonic or near-isotonic crystalloids for fluid resuscitation in trauma patients.[40]

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