Prolonged hypernatremia safely controls elevated intracranial pressure in pediatric head injury patients

Introduction

The standard treatment of elevated intracranial pressure (ICP) includes the administration of hyperosmotic solutions. Osmolar diuretics may lead to intravascular dehydration, hypotension, pre-renal azotemia and reduction of cerebral blood flow. Hypertonic saline solutions effectively reduce raised intracranial pressure in animals and humans without producing intravascular dehydration. We evaluated the degree of intracranial pressure control induced by the administration of 3% hypertonic saline (508 mOsms/I NaCl) in pediatric patients after traumatic brain injury.

Methods

We retrospectively reviewed the charts of 68 children who suffered traumatic brain injury with intracranial hypertension (ICP >20 mmHg). These patients received the conventional modalities for the treatment of intracranial hypertension including elevation of head (15°), pain control, hyperventilation, mannitol and sodium thiopentothal administration. In addition, they received continuous 3% saline infusions to reduce intracranial pressure below 20 mmHg. Hypertonic saline infusions were continuous and ranged between 2–7 days depending upon the patient's requirement for control of raised intracranial pressure.

Results

The mean dose of 3% saline was 17.23 ± 5 ml/kg/day. The highest, lowest and average serum sodium was 182, 140 and 158 ± 28 mEq/l respectively. The mean daily dose of mannitol was 2 ± 0.65 gm/kg/day. The highest, lowest and average serum osmolarity was 380, 276 and 316 ± 39 mOsm/l respectively. The mean serum creatinine was 0.7 ± 0.3 mg/dl. The intracranial pressure averaged 20 mmHg 92% of the time, 20–30 mmHg 7% and greater than 30 mmHg 1% of the time during the first seven days post injury. Ten (15%) of 68 patients expired. However only two (3%) children died of uncontrolled intracranial hypertension.

Conclusions

We conclude that administration of 3% hypertonic saline to pediatric brain injured patients with elevated intracranial pressure in conjunction with standard treatment modalities results in effective control of intracranial pressure. Hypernatremia and hyperosmolarity are safely tolerated in brain injured pediatric patients.