Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in pediatric traumatic brain injury

Objectives: To evaluate the effect of prolonged infusion of 3% hypertonic s aline (514 mEq/L) and sustained hypernatremia on refractory intracranial hy pertension in pediatric traumatic brain injury patients. Design: A prospective study. Setting: a 24-bed Pediatric Intensive Care Unit (Level III) at Children's H ospital. Patients: We present ten children with increased intracranial pressure (ICP ) resistant to conventional therapy (head elevation at 30 degrees, normothe rmia, sedation, paralysis and analgesia, osmolar therapy with mannitol, loo p diuretic, external vertricular drainage in five patients), controlled hyp erventilation (PCO2, 28-35 mm Hg), and barbiturate coma. We continuously mo nitored ICP, cerebral perfusion pressure (CPP), mean arterial pressure, cen tral venous pressure, serum sodium concentrations, serum osmolarity, and se rum creatinine. Interventions: A continuous infusion of 3% saline on a sliding scale was us ed to achieve a target serum sodium level that would maintain ICP <20 mm Hg once the conventional therapy and barbiturate coma as outlined above faile d to control intracranial hypertension. Measurements and Main Results: The mean duration of treatment with 3% salin e was 7.6 days (range, 4-18 days). The mean highest serum sodium was 170.7 mEq/L (range, 157-187 mEq/L). The mean highest serum osmolarity was 364.8 m osm/L (range, 330-431 mosm/L). The mean highest serum creatinine was 1.31 m g/dL (range, 0.4-5.0 mg/dL). There was a steady increase in serum sodium ve rsus time zero that reached statistical significance at 24, 48, and 72 hrs (p < .01). There was a statistically significant decrease in ICP spike freq uency at 6, 12, 24, 48, and 72 hrs (p < .01). There was a statistically sig nificant increase in CPP versus time zero at 6, 12, 24, 48, and 72 hrs (p < .01). There was a statistically significant increase in serum osmolarity v ersus time zero at 12 hrs (p < .05) and at 24, 48, and 72 hrs (p < .01). Tw o patients developed acute renal failure and required continuous veno-venou s hemodialysis; these were concurrent with an episode of sepsis and multisy stem organ dysfunction. Both recovered full renal function with no electrol yte abnormalities at the time of discharge. Conclusion: An increase in serum sodium concentration significantly decreas es ICP and increases CPP. Hypertonic saline is an effective agent to increa se serum sodium concentrations. Sustained hypernatremia and hyperosmolarity are safely tolerated in pediatric patients with traumatic brain injury. Co ntrolled trials are needed before recommendation of widespread use.