Hypertonic Saline Use in Heart Failure

Mechanism of Action and Clinical Evidence

Hypertonic saline works primarily through osmotic fluid shifts from the intracellular to the interstitial and intravascular spaces, with sodium having a reflection coefficient of 1 across cell membranes 1
Hypertonic saline can increase intravascular volume by up to four times the infused volume within minutes of administration, providing more effective plasma volume expansion than isotonic crystalloids 1

The American College of Cardiology recommends higher doses of loop diuretics for patients with diuresis inadequate to relieve congestion 2
The American College of Cardiology recommends the addition of a second diuretic, such as metolazone, spironolactone, or IV chlorothiazide, for patients with diuresis inadequate to relieve congestion 2
The American College of Cardiology recommends continuous infusion of a loop diuretic for patients with diuresis inadequate to relieve congestion 2
For patients with advanced heart failure and hyponatremia, the benefit of fluid restriction to reduce congestive symptoms is uncertain (Class 2b, Level of Evidence C-LD) 3

Hypertonic saline should be used cautiously in patients with heart failure as it can potentially worsen fluid overload if not properly balanced with effective diuresis 5
Monitoring of serum electrolytes, particularly sodium, is essential during hypertonic saline administration 3
Monitoring of renal function is essential during hypertonic saline administration 6, 7