Predictable reduction of intracranial hypertension with hypertonic saline hydroxyethyl starch: a prospective clinical trial in critically ill patients with subarachnoid haemorrhage.
BACKGROUND
After head trauma, hypertonic saline lowers intracranial pressure (ICP) and preserves or increases cerebral perfusion pressure (CPP). Hypertonic saline has not been studied in patients with increased ICP due to subarachnoid haemorrhage (SAH). The aim of this study was to evaluate the effects on elevated ICP and on CPP in patients critically ill from SAH.


METHODS
Critically ill SAH-patients needing urgent treatment for an elevated ICP, but otherwise stable, were included in this study. We infused 7.2% saline in 6% hydroxyethyl starch (HyperHAES((R)) Fresenius Kabi AG, Bad Homburg v.d.h., Germany) 2 ml kg(-1) during 20 min in 10 episodes of ICP > 20 mmHg in seven patients with SAH. Our primary outcome variables were changes in ICP and CPP during and for 3 h after this infusion.


RESULTS
All interventions resulted in decreased ICP and elevation of CPP. The mean value for maximum ICP decrease in percent of baseline was 58% (range 43-83%, P = 0.002), which occurred at mean 40 min (range 25-90 min) after start of infusion. The mean percent peak increase in CPP was 26% (range 16-32%, P = 0.002). After 210 min, ICP was 35% lower than baseline (range 19-39%, P = 0.008). Serum sodium increase was mean 6.6 mmol l(-1) (range 5-9 mmol l(-1)) 30 min after start of infusion.


CONCLUSIONS
7.2% saline in 6% hydroxyethyl starch is an effective and safe therapy for intracranial hypertension after SAH. We demonstrate that an infusion of 2 ml kg(-1) during 20 min has a predictable and clinically significant beneficial effect on ICP and CPP. The effect was still present 3 h after end of infusion. Rebound ICP-increase was not observed within 3 h.
Bentsen
G
G
Department of Anaesthesiology, Rikshospitalet University Hospital, Oslo, Norway. gunnar.bentsen@rikshospitalet.no
Breivik
H
H
Lundar
T
T
Stubhaug
A
A
D000328:Adult; D001810:Blood Volume / Q000187:drug effects; D002560:Cerebrovascular Circulation / Q000187:drug effects; D016638:Critical Illness; D015633:Extravascular Lung Water / Q000187:drug effects; D005260:Female; D006439:Hemodynamics / Q000187:drug effects; D006801:Humans; D006895:Hydroxyethyl Starch Derivatives / Q000009:adverse effects / Q000627:therapeutic use*; D019586:Intracranial Hypertension / Q000188:drug therapy* / Q000209:etiology; D008297:Male; D008875:Middle Aged; D009994:Osmolar Concentration; D010952:Plasma Substitutes / Q000009:adverse effects / Q000627:therapeutic use*; D011446:Prospective Studies; D012462:Saline Solution, Hypertonic; D013345:Subarachnoid Hemorrhage / Q000188:drug therapy* / Q000503:physiopathology
D006895:Hydroxyethyl Starch Derivatives; D010952:Plasma Substitutes; D012462:Saline Solution, Hypertonic