Method of Hypertonic Saline Administration: Effects on Osmolality in Traumatic Brain Injury Patients

Hypertonic saline (HTS) is an effective therapy for reducing intracranial pressure (ICP). The ideal method of administration is unknown. The purpose of this study was to evaluate the method of HTS infusion and time to goal osmolality. A retrospective cohort analysis was conducted in severe TBI patients with ICP monitoring in place who received 2 doses of HTS. Patients were divided into bolus versus continuous infusion HTS cohorts. The primary outcome was median time to goal osmolality. Secondary outcomes included percentage of patients reaching goal osmolality, percent time at goal osmolality, mean cerebral perfusion pressure (CPP) and ICP, ICU length of stay, and mortality. Safety outcomes included rates of hyperchloremia, hypernatremia, and acute kidney injury (AKI). 162 patients were included with similar baseline characteristics. Time to goal osmolality was similar between cohorts (bolus 9.78h vs. continuous 11.4h, p=0.817). A significant difference in the percentage of patients reaching goal osmolality favoring the continuous group was found (93.9% vs 73.3%, p=0.003). The continuous group was maintained at goal osmolality for a higher percentage of osmolality values after reaching goal (80% vs. 50%, p=0.032). No difference was seen in CPP, ICP, length of stay and mortality. Rates of hypernatremia were similar, but significant higher rates of hyperchloremia (0.77vs 1.58 events per HTS days, p<0.001) and AKI (0% vs 12.9%, p=0.025) were observed in the continuous cohort. Although no difference in time to goal osmolality was observed, continuous HTS was associated with a higher percentage of patients achieving goal osmolality.