Hypertonic saline in emergent situations

[storyhill2]

In some instances we need to give a concentrated fluid to try decrease ICP. The last one I had this week was a possible cerebral hernia with a trauma patient and cardiac arrest. I have had this happen a few times, but in the past we've used mannitol and the dosing and administration time for that is pretty straight forward. Weight based I think over 30 minutes. This time the doctor asked for a bolus of 100 ml hypertonic saline. I asked if we could do mannitol and he insisted he wanted to do hypertonic saline. I haven't found any good resources for how to dose it and how fast to give. The doctor didn't know and neither did I. The flight crew was in the room and their nurse said they usually do 250 ml over 20 minutes. It seems in that situation it probably is fine but I am just unable to find a good resource. Anyone have experience with this or/and have any resource to educate myself? Thanks.

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[Radetzky]

150 mls of the 3% as fast as it will go. Or a slow push of 23.4%

 

[sunnyandseventytwo]

Isn't there an uptodate protocol on this? Pretty sure my hospital copied its order set from uptodate. We're pretty hardcore cutting edge like that.

 

[TheBlaah]

We usually do 100ml of 3% over 10 minutes, possibly followed by a drip of 10-40ml/hr with sodium levels every 2 hours.

I've only seen my hospital once do a slow push of 23.4% 50mL immediately prior to emergency brain surgery, and a provider had to do it.

 

[storyhill]

Isn't there an uptodate protocol on this? Pretty sure my hospital copied its order set from uptodate. We're pretty hardcore cutting edge like that.

I searched all over uptodate and can't find something specific except for an article talking about 30 ml bolus over 10 min. It wasn't the same indication. I just went back and checked again and did find this in the article about "treatment of hyponatremia".

"In acutely hyponatremic patients with a serum sodium <130 mEq/L who have any symptoms that might be due to increased intracranial pressure (seizures, obtundation, coma, respiratory arrest, headache, nausea, vomiting, tremors, gait or movement disturbances, or confusion), we treat with a 100 mL bolus of 3 percent saline, followed, if symptoms persist, with up to two additional 100 mL doses (to a total dose of 300 mL); each bolus is infused over 10 minutes. An alternative approach, recommended in by European organizations, is to treat with two 150 mL bolus infusions of 3 percent saline, each given over 20 minutes, measuring the serum sodium between infusions"


This isn't the same indication but at least it's showing 100 ml over 10 minutes seems reasonable. I can remember that pretty easy too.

I was hoping to find something specific to "cerebral hernia in trauma" or something and talking about the use of hypertonic saline in this instance. This may be the best I got. It's better than what I knew 5 days ago.

Thanks for the input. Nice to hear what others do.

 

[sunnyandseventytwo]

I searched all over uptodate and can't find something specific except for an article talking about 30 ml bolus over 10 min. It wasn't the same indication. I just went back and checked again and did find this in the article about "treatment of hyponatremia".

"In acutely hyponatremic patients with a serum sodium <130 mEq/L who have any symptoms that might be due to increased intracranial pressure (seizures, obtundation, coma, respiratory arrest, headache, nausea, vomiting, tremors, gait or movement disturbances, or confusion), we treat with a 100 mL bolus of 3 percent saline, followed, if symptoms persist, with up to two additional 100 mL doses (to a total dose of 300 mL); each bolus is infused over 10 minutes. An alternative approach, recommended in by European organizations, is to treat with two 150 mL bolus infusions of 3 percent saline, each given over 20 minutes, measuring the serum sodium between infusions"


This isn't the same indication but at least it's showing 100 ml over 10 minutes seems reasonable. I can remember that pretty easy too.

I was hoping to find something specific to "cerebral hernia in trauma" or something and talking about the use of hypertonic saline in this instance. This may be the best I got. It's better than what I knew 5 days ago.

Thanks for the input. Nice to hear what others do.

Sorry, I can't get uptodate on my phone, so can't cut and paste. It's referenced in a couple of places: "management of acute moderate and severe traumatic brain injury" and "evaluation and management of elevated intracranial pressure in adults". Neither has as much detail as I remember...it's possible they've edited the articles down a little. The first one should give you enough info to at least determine if the order before you makes sense.

 

[Dred Pirate]

250ml of 3 % over 15 min or slow IVP of 30 ml 23.4%

 

[lymphocyte]

You can also just use 8.4% sodium bicarb. It's in every crash cart. About 100mLs over 20 minutes.

Emergent treatment of hyponatremia or elevated ICP with bicarb ampules

. Introductory case . A young 70-kg man was transferred to the Genius GeneralICU for management of stupor. He had been diagnosed with aortic valve

emcrit.org

 

[storyhill]

250ml of 3 % over 15 min or slow IVP of 30 ml 23.4%

Yeah, that's about what the flight nurse said they do.

 

[storyhill]

You can also just use 8.4% sodium bicarb. It's in every crash cart. About 100mLs over 20 minutes.

Emergent treatment of hyponatremia or elevated ICP with bicarb ampules

. Introductory case . A young 70-kg man was transferred to the Genius GeneralICU for management of stupor. He had been diagnosed with aortic valve

emcrit.org

I never even thought about that. Pretty good idea. I can usually get 3% saline within a few minutes from central pharmacy but even getting the tubing ready takes another few minutes also. Probably average of 10 minutes to get it started. Sodium bicarb could be in by that time. Great article. Thanks for providing some sourcing and an article.

 

[chord]

We prefer hypertonic saline to mannitol in trauma situations as it doesn’t volume deplete a patient who may already be volume depleted from blood loss. I’ll usually give 225-300 cc 5% in a normal sized person “as fast as it’ll go” or, if able, approx 45 cc 23.4%. If there’s a problem acquiring the HTS and the patient is hemodynamically stable and I need to give hyperosmolar therapy, I’ll give mannitol. Or if the ED gives something before talking to us or trauma surgery, sometimes mannitol is given instead too. Renal issues? HTS > MTL also.

 

[Rockinacoustic]

We prefer hypertonic saline to mannitol in trauma situations as it doesn’t volume deplete a patient who may already be volume depleted from blood loss. I’ll usually give 225-300 cc 5% in a normal sized person “as fast as it’ll go” or, if able, approx 45 cc 23.4%. If there’s a problem acquiring the HTS and the patient is hemodynamically stable and I need to give hyperosmolar therapy, I’ll give mannitol. Or if the ED gives something before talking to us or trauma surgery, sometimes mannitol is given instead too. Renal issues? HTS > MTL also.

By problem acquiring HTS I assume that's because your pharmacy doesn't stock it on the units in your pyxis?

We loaded 3% HTS in our ED pyxis machines - you should ask for the same

 

[chord]

By problem acquiring HTS I assume that's because your pharmacy doesn't stock it on the units in your pyxis?

We loaded 3% HTS in our ED pyxis machines - you should ask for the same

With the 23.4%, more of an access issue because our hospital won’t give it through a peripheral (seems reasonable), and occasionally no one can find 5%. Our children’s hospital only stocks 3% so that’s what we end up using there.