Hypertonic saline

[Operations Guy]

The hetastarches (Hextend and Hespan) got a pretty good ride about 10 years ago because they were seen as a clean (non blood product) quick volume expander that stayed intravascular (about 40% of the infused volume over 24 hr). I used them a lot but they were implicated with AKI in critical patients and bleeding with doses over 20 or so ml/kg. But some of that data was from animal models and I think the Europeans made a statement along those that more or less ended it's use. The FDA put out a warning and that was that. Too bad, to, because it was really useful.

Of course cause the European Medical and FDA opinions was based on civilian application and not it's designed application. It's application is proven and shown to be successful. Also European Medical and FDA groups where testing it on sepsis patients and patients already with one foot in the grave. I found its proper application outweighed all risk. The target of the application was healthy younger males with massive blood loss not little old ladies.

 

[Brandon O]

Arguments against mannitol for elevated ICP include its rather potent osmotic diuresis (requiring vigorous fluid repletion to avoid hypovolemia, which is not desirable in these people).

Arguments for are mainly that it's perceived as being safe in peripheral lines. Hence, mannitol until you get a central line, then perhaps hypertonic, would be one approach.

(Hypertonic is contraindicated via IO in some places, but I don't think this position is well supported.)

 

[E tank]

Arguments against mannitol for elevated ICP include its rather potent osmotic diuresis (requiring vigorous fluid repletion to avoid hypovolemia, which is not desirable in these people).
QUOTE]

Nah...there's more than giving volume to maintain CPP. Besides, neurosurgeons absolutely love dry patients. Gives the nephrologists something to do

 

[Brandon O]

Nah...there's more than giving volume to maintain CPP. Besides, neurosurgeons absolutely love dry patients. Gives the nephrologists something to do

Hmm... no neurosurgeons I've met. (Actually, I haven't found any that care very much -- they leave silly things like fluid balance to us ICU types.)

Neurocritical care folks do like their phenylephrine, but trying to respond to hypovolemia with anything but volume is really an uphill battle no matter your setting.

 

[E tank]

Hmm... no neurosurgeons I've met. (Actually, I haven't found any that care very much -- they leave silly things like fluid balance to us ICU types.)

QUOTE]

How do you manage volume replacement in crani patients (post aneurysm clipping or tumor excision?)

 

[Brandon O]

How do you manage volume replacement in crani patients (post aneurysm clipping or tumor excision?

Need a bit more detail there... are we talking about patients who are herniating and receiving mannitol or hypertonic (per the above discussion)? Patients with DI? Routine postop care?

 

[E tank]

Need a bit more detail there... are we talking about patients who are herniating and receiving mannitol or hypertonic (per the above discussion)? Patients with DI? Routine postop care?

Patients getting mannitol. How do you guide fluid management?

 

[Alan L Serve]

Even in the ER hypertonic saline is only used under carefully controlled and monitored situations. Even then it's only done 15mL at a time. Even then it's only with close serial Na+ monitoring in PTs who are seizing due to hyponatremia. Even then there are often other options.

 

[Brandon O]

Patients getting mannitol. How do you guide fluid management?

Essentially like anybody else: fluid or pressors based upon your assessment of their fluid responsiveness and based upon your BP/CPP goals (surgeons do have an opinion about that!); but with the recognition that if their urine output is high they likely need volume to replace it. Would follow labs but likely start with NS.

That being said we tend to use more hypertonic used, at least after the initial phase (and after somebody gets a line in).

This is not really my strength BTW so I welcome input from anyone with a stronger background in neurocritical care.

 

[E tank]

Essentially like anybody else: fluid or pressors based upon your assessment of their fluid responsiveness and based upon your BP/CPP goals (surgeons do have an opinion about that!); but with the recognition that if their urine output is high they likely need volume to replace it. Would follow labs but likely start with NS.

That being said we tend to use more hypertonic used, at least after the initial phase (and after somebody gets a line in).

This is not really my strength BTW so I welcome input from anyone with a stronger background in neurocritical care.

I was just asking, because the point of hyperosmolar therapy is to shrink the brain not only for treatment of intracranial htn, but also to maximize exposure for the surgeons in the operating room, giving a "slack brain" to work with and minimizing post op cerebral edema. Volume management is only to avoid hypovolemia, and that is a pretty broad spectrum. Euvolemia with a rising CVP defeats the purpose. Surgeons can tell just by looking at the brain that too much fluid has been given, which can be a very reasonable and modest amount even with conventional replacement strategies are used. Pretty challenging to get just right.

It's a pretty broad topic to be discussed in forum format, I just wanted to get a feel for what folks do.

 

[E tank]

Even in the ER hypertonic saline is only used under carefully controlled and monitored situations. Even then it's only done 15mL at a time. Even then it's only with close serial Na+ monitoring in PTs who are seizing due to hyponatremia. Even then there are often other options.

You probably use HTS for folks with subarachnoid bleeds as well. There's a difference correcting serum Na too quickly for hyponatremia and using it for a SA bleed/ herniation rescue. In that case, taking the sodium up to even the mid 150's hasn't been shown to be detrimental.

It can get confusing when the seizures are being caused by a bleed v. hyponatremia. Different deal.

 

[Brandon O]

I was just asking, because the point of hyperosmolar therapy is to shrink the brain not only for treatment of intracranial htn, but also to maximize exposure for the surgeons in the operating room, giving a "slack brain" to work with and minimizing post op cerebral edema. Volume management is only to avoid hypovolemia, and that is a pretty broad spectrum. Euvolemia with a rising CVP defeats the purpose. Surgeons can tell just by looking at the brain that too much fluid has been given, which can be a very reasonable and modest amount even with conventional replacement strategies are used. Pretty challenging to get just right.

It's a pretty broad topic to be discussed in forum format, I just wanted to get a feel for what folks do.

Sure. I haven't heard the neurosurgeons in our neck of the woods ask for us to keep these folks dry; practice may differ. Once they decompress, they tend to leave the skull open for a long time (months), so there's no real need to vigorously shrink the parenchyma.

 

[LaAranda]

Grand Canyon National Park medics uses hypertonic saline for field treatment of severe acute hyponatremia, confirmed via field lab testing. I believe the protocol allows for several 100ml or so boluses for those with serum sodium <130 or so. I would have to dig a little for the exact details.

 

[NomadicMedic]

Grand Canyon National Park medics uses hypertonic saline for field treatment of severe acute hyponatremia, confirmed via field lab testing. I believe the protocol allows for several 100ml or so boluses for those with serum sodium <130 or so. I would have to dig a little for the exact details.

Wow. Istat in the truck? I'd be interested in seeing the whole set of protocols. I'd bet there's some other gems in there.

 

[LaAranda]

Wow. Istat in the truck? I'd be interested in seeing the whole set of protocols. I'd bet there's some other gems in there.

Yes, it's a neat service - met a few folks who have worked there. Not sure if they have other therapies available for other abnormal labs, although I believe they check trops.

 

[Alan L Serve]

Grand Canyon National Park medics uses hypertonic saline for field treatment of severe acute hyponatremia, confirmed via field lab testing. I believe the protocol allows for several 100ml or so boluses for those with serum sodium <130 or so. I would have to dig a little for the exact details.

100mL bolus of hypertonic saline=death

 

[Operations Guy]

Per Emsworld Nov 1 2013

"As a current example, Grand Canyon National Park, which has a large number of heat-illness patients, is working on a treatment protocol for hyponatremia that involves infusion of a hypertonic saline solution based on some the latest treatment research. They have a local medical control physician who has researched this topic and developed the protocol with NPS staff at the Grand Canyon. It is currently being reviewed at Fresno for final approval, as are any park-specific protocols."

 

[LaAranda]

100mL bolus of hypertonic saline=death

Not in a pt. with severe acute exercise-induced hyponatremia. This is a very specific clinical context; these are not geriatrics with severe kidney disease, they're healthy 30 year olds who went from baseline to serum sodiums in the 110s in only a few hours. Rapid correction is indicated.

 

[Alan L Serve]

Not in a pt. with severe acute exercise-induced hyponatremia. This is a very specific clinical context; these are not geriatrics with severe kidney disease, they're healthy 30 year olds who went from baseline to serum sodiums in the 110s in only a few hours. Rapid correction is indicated.

If you do 100mL slowly over 10 minutes or so you'd be ok. That's not a "bolus".

 

[LaAranda]

If you do 100mL slowly over 10 minutes or so you'd be ok. That's not a "bolus".

I will reach out for the exact protocol. I believe it's given quicker than 10 minutes. Running a burette wide-open for a few minutes isn't a bolus because it's not pushed? Do you think the term 'fluid bolus' is widely misused/misunderstood then?