Management of Intracranial Hypertension with Hypertonic Saline

Introduction to Hypertonic Saline Therapy

The American Heart Association recommends the use of hypertonic saline for the management of intracranial hypertension, with a target sodium serum level of 140-150 mEq/L 1, 2
Hypertonic saline has been shown to be superior to mannitol in reducing intracranial pressure and improving cerebral perfusion pressure, with a longer duration of action 1, 2

Studies have demonstrated a reduction in perihaematoma edema and a trend towards decreased mortality with the use of hypertonic saline, although high-quality randomized controlled trials are still needed to confirm these findings 1, 2
The use of hypertonic saline has been associated with a lower risk of acute kidney injury when compared to mannitol, although careful monitoring of renal function is still necessary 3

The European Society of Intensive Care Medicine recommends the use of hypertonic saline as a first-line treatment for intracranial hypertension, with a dose of 0.5-2 mL/kg/hour 1, 2
The American College of Critical Care Medicine suggests that hypertonic saline should be used with caution in patients with congestive heart failure or volume overload, and that alternative treatments should be considered in these cases 3

Hypertonic saline should not be used for volume resuscitation in hemorrhagic shock without intracranial hypertension, and should be avoided in patients with congestive heart failure or volume overload 3
The use of hypotonic solutions, including Ringer's lactate, should be avoided in patients with acute brain injury due to the risk of increased mortality 3

The American College of Surgeons recommends the use of hypertonic saline (NaCl 3%) for the management of refractory intracranial hypertension and symptomatic cerebral edema in patients with intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH), due to its osmotic effects 4
The use of NaCl 3% as a first-line fluid therapy for hemorrhagic shock is not recommended (GRADE 1 - strong recommendation), as a meta-analysis of 2,932 patients showed no mortality benefit compared to isotonic solutions 5, 4

The European Society of Anaesthesiology recommends the use of balanced crystalloids (Ringer's Lactate or Plasmalyte) as the first-line fluid for resuscitation in patients with ICH/IVH, instead of NaCl 3% 5, 6
Balanced crystalloids are associated with better acid-base balance and potentially lower mortality rates 5, 6
Hypotonic solutions such as Ringer's Lactate should be avoided in severe traumatic brain injury due to the risk of fluid shift into damaged cerebral tissue 7

The American Heart Association warns against the use of NaCl 3% for volume resuscitation in ICH without refractory intracranial hypertension or symptomatic cerebral edema 5, 4
The use of NaCl 0.9% should be limited to a maximum of 1-1.5 liters due to the risk of hyperchloremic metabolic acidosis 8, 6
In patients with large ICH requiring intracranial pressure monitoring or severe IVH with external ventricular drainage, cerebral perfusion pressure should be maintained at 60-70 mmHg during blood pressure reduction 9