Hypertonic saline in paediatric traumatic brain injury: a review of nine years' experience with 23.4% hypertonic saline as standard hyperosmolar therapy
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Published on: June 6, 2011
1Department of Anaesthesia and Intensive Care, John Hunter Hospital, Newcastle, New South Wales.
Insights
23.4% hypertonic saline solution (HTS) effectively manages intracranial hypertension in pediatric traumatic brain injury patients. This large study shows favorable outcomes, including reduced mortality and improved functional status, with manageable biochemical effects.
Area of Science:
- Pediatric Critical Care Medicine
- Neurotrauma Management
- Emergency Medicine
Background:
- Intracranial hypertension (ICH) is a critical complication of pediatric traumatic brain injury (TBI).
- Effective management of ICH is crucial for improving patient outcomes and reducing mortality.
- Hypertonic saline solution (HTS) is used to manage ICH, but data on high-concentration HTS in pediatrics is limited.
Purpose of the Study:
- To evaluate the efficacy and safety of 23.4% hypertonic saline solution (HTS) for managing intracranial hypertension in pediatric patients with traumatic brain injury.
- To analyze the biochemical and metabolic consequences of 23.4% HTS administration.
- To assess patient outcomes, including mortality and functional status.
Main Methods:
- Retrospective cohort study conducted in a Level 1 pediatric trauma center.
- Analysis of data from pediatric patients treated with 23.4% HTS for traumatic brain injury-related intracranial hypertension.
- Evaluation of mortality, intensive care unit (ICU) length-of-stay, intracranial pressure (ICP) response, and biochemical parameters (serum sodium, chloride, base excess, creatinine).
- Assessment of Glasgow Outcome Scores (GOS) at follow-up.
Main Results:
- The study included 32 pediatric patients. Seven-day mortality was 6% (2/32), and all-cause hospital mortality was also 6%.
- Mean ICU length-of-stay was 10 days. Mean ICP reduction following HTS administration was 10 mmHg.
- Mean peak serum sodium was 148 mmol/l, mean peak serum chloride was 115 mmol/l, and mean peak serum creatinine was 73 mmol/l.
- 74% of patients achieved a Glasgow Outcome Score >3 (indicating independent function).
Conclusions:
- 23.4% HTS is a practical and effective method for delivering osmoles to manage intracranial hypertension in pediatric TBI.
- The use of 23.4% HTS demonstrated favorable clinical outcomes, including low mortality and good functional recovery.
- Combining bolus and infusion strategies for HTS administration may be optimal for managing ICH in this population.
Abstract:
We describe the protocolised use of 23.4% hypertonic saline solution (HTS) for intracranial hypertension in the context of traumatic brain injury in the paediatric population. This study represents the largest published data on the use of 23.4% HTS in the paediatric population. In this retrospective cohort, we focus on the efficacy, biochemical and metabolic consequences of 23.4% HTS administration in a Level 1 paediatric trauma centre. Mortality in the first seven days was 6% (2/32) with a mean intensive care unit length-of-stay of ten days (range 2 to 25, standard deviation [SD] 6). All-cause hospital mortality was 6%, with no deaths after the seven-day study period. Mean intracranial pressure (ICP) response to HTS was 10 mmHg (range 1 to 30, SD 8). For biochemistry data, the mean highest daily serum sodium was 148 mmol/l (139 to 161, SD 6), mean highest serum chloride was 115 mmol/l (range 101 to 132, SD 8) with matched mean serum base excess of -1.5 mmol/l (range 2 to -8, SD 3) and mean peak serum creatinine was 73 mmol/l (range 32 to 104, SD 32). Glasgow outcome scores of >3 (independent function) were achieved in 74% of patients. We describe the use of 23.4% HTS, demonstrating it to be a practical and efficacious method of delivering osmoles and may be advantageous in minimising total fluid volume. Thus, the bolus versus infusion debate may best be served via combining both approaches.
