title: Effective treatment of refractory intracranial hypertension after traumatic brain injury with repeated boluses of 14.6% hypertonic saline.
abstract: OBJECTIVE
  Normal intracranial pressure (ICP) and cerebral perfusion pressure (CPP) have been identified as favorable prognostic factors in the outcome of patients with traumatic brain injuries (TBIs). Osmotic diuretics and hypertonic saline (HTS) are commonly used to treat elevated ICP in patients with TBI; however, sustained effects of repeated high-concentration HTS boluses for severely refractory ICP elevation have not been studied. The authors' goal in this study was to determine whether repeated 14.6% HTS boluses were efficacious in treating severely refractory intracranial hypertension in patients with TBI.
  
  
  METHODS
  In a prospective cohort study in a neurocritical care unit, adult TBI patients with sustained ICP > 30 mm Hg for more than 30 minutes after exhaustive medical and/or surgical therapy received repeated 15-minute boluses of 14.6% HTS over 12 hours through central venous access.
  
  
  RESULTS
  Response to treatment was evaluated in 11 patients. Within 5 minutes of bolus administration, mean ICP decreased from 40 to 33 mm Hg (30% reduction, p < 0.05). Intracranial pressure-lowering effects were sustained for 12 hours (41% reduction, p < 0.05) with multiple boluses (mean number of boluses 7 ± 5.5). The mean CPP increased 22% and 32% from baseline at 15 and 30 minutes, respectively (p < 0.05). The mean serum sodium level (SNa) at baseline was 155 ± 7.1 mEq/L, and after multiple boluses of 14.6% HTS, S(Na) at 12 hours was 154 ± 7.1 mEq/L. The mean heart rate, systolic blood pressure, blood urea nitrogen, and creatinine demonstrated no significant change throughout the study.
  
  
  CONCLUSIONS
  The subset of TBI patients with intracranial hypertension that is completely refractory to all other medical therapies can be treated effectively and safely with repeated boluses of 14.6% HTS rather than a one-time dose.
authors.affiliation: Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA.
authors.forename: Ramin
authors.initials: R
authors.lastname: Eskandari
authors.forename: Michael R
authors.initials: MR
authors.lastname: Filtz
authors.forename: Gary E
authors.initials: GE
authors.lastname: Davis
authors.forename: Robert E
authors.initials: RE
authors.lastname: Hoesch
mesh_terms: D000328:Adult; D000368:Aged; D001794:Blood Pressure / Q000187:drug effects; D001930:Brain Injuries / Q000150:complications*; D005260:Female; D006801:Humans; D019586:Intracranial Hypertension / Q000188:drug therapy* / Q000209:etiology; D007427:Intracranial Pressure / Q000187:drug effects*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012462:Saline Solution, Hypertonic / Q000008:administration & dosage / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D012462:Saline Solution, Hypertonic