Literature Review #21. 23.4% Hypertonic Saline

BACKGROUND

• In patients with acute brain injury, sustained intracranial hypertension is considered a medical emergency that requires immediate recognition and treatment to prevent progression of cerebral ischemia, brain herniation, and death. Recommended treatment is hyperosmolar therapy with mannitol or hypertonic saline. 23.4% saline is an effective treatment, but historically requires administration via IV infusion.

STUDY OBJECTIVE

• Prospectively evaluate the safety of administration of 23.4% NaCl as rapid IV push over 2-5 mins

STUDY DESIGN

• Single-center prospective, observational analysis

Study Intervention & Comparison

• Documented administration of 23.4% NaCl over 2-5 mins

Results

• Primary Safety Outcome
  • Composite incidence of hypotension, bradycardia, and infusion site reaction within 60 mins
  • Reported in 31% of unique patients following 15% of administrations
    • All instances of fall in SBP by at least 20mmHg associated with potential alternative or exacerbating factors
    • All instances of SBP <90mmHg were in patients already on vasopressor support
    • One instance of infusion site reaction (pain)
• Secondary Safety Outcome
  • Comparison of highest and lowest SBP values and lowest heart rate documented within 60 mins
    • No significant changes observed

Summary

• IV push administration of 23.4% NaCl over 2-5 minutes may be considered a safe, alternative method of administration.

Additional Readings

• Faiver L, Hensler D, Rush SC, Kashlan O, Williamson CA, Rajajee V. Safety and efficacy of 23.4% sodium chloride administered via peripheral venous access for the treatment of cerebral herniation and intracranial pressure elevation. Neurocrit Care. 2021;35(3):845–52
• Rockswold GL, Solid CA, Paredes-Andrade E, Rockswold SB, Jancik JT, Quickel RR. Hypertonic saline and its effect on intracranial pressure, cerebral perfusion pressure, and brain tissue oxygen. Neurosurgery. 2009;65(6):1035–41.
• Ware ML, Nemani VM, Meeker M, Lee C, Morabito DJ, Manley GT. Effects of 23.4% sodium chloride solution in reducing intracranial pressure in patients with traumatic brain injury: a preliminary study. Neurosurgery. 2005;57(4):727–36