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Letter| Volume 37, ISSUE 5, P981-983, May 2019

Pediatric hypertonic saline use in emergency departments

Published:September 28, 2018DOI:https://doi.org/10.1016/j.ajem.2018.09.040
Pediatric hypertonic saline use in emergency departments
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      Hypertonic saline (HTS) is often used to manage cerebral edema and increased intracranial pressure (ICP) in children via creation of an osmolar gradient which promotes decreases in brain interstitial volume along the blood-brain barrier [
      • Hinson H.E.
      • Stein D.
      • Sheth K.N.
      Hypertonic saline and mannitol therapy in critical care neurology.
      J Intensive Care Med. Jan-Feb 2013; 28: 3-11
      ]. It also acts as a plasma volume expander. There is scant evidence directing administration in children [
      • Fisher B.
      • Thomas D.
      • Peterson B.
      Hypertonic saline lowers raised intracranial pressure in children after head trauma.
      J Neurosurg Anesthesiol. 1992; 4: 4-10
      ,
      • Kochanek P.M.
      • Carney N.
      • Adelson P.D.
      • Ashwal S.
      • Bell M.J.
      • Bratton S.
      • et al.
      Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents—second edition.
      Pediatr Crit Care Med. 2012; 13: S1-82https://doi.org/10.1097/PCC.0b013e31823f435c
      ,
      • Fisher B.
      • Thomas D.
      • Peterson B.
      Hypertonic saline lowers raised intracranial pressure in children after head trauma.
      J Neurosurg Anesthesiol. 1992; 4: 4-10
      ] resulting in variation in emergency physician practices [
      • Berger Pelletier E.
      • Emond M.
      • Lauzier F.
      • Savard M.
      • Turgeon A.F.
      Hyperosmolar therapy in severe traumatic brain injury: a survey of emergency physicians from a large Canadian province.
      PLoS One. 2014; 9e95778
      ,
      • Kochanek P.M.
      • Carney N.
      • Adelson P.D.
      • Ashwal S.
      • Bell M.J.
      • Bratton S.
      • et al.
      Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents—second edition.
      Pediatr Crit Care Med. 2012; 13: S1-82https://doi.org/10.1097/PCC.0b013e31823f435c
      ]. HTS exhibits low rates of adverse effects, even with the use of intravenous (IV) concentrations through 23.4% [
      • Kochanek P.M.
      • Carney N.
      • Adelson P.D.
      • Ashwal S.
      • Bell M.J.
      • Bratton S.
      • et al.
      Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents—second edition.
      Pediatr Crit Care Med. 2012; 13 (Epub 2012/01/11, PubMed PMID: 22217782): S1-82https://doi.org/10.1097/PCC.0b013e31823f435c
      ,
      • Kerwin A.J.
      • Schinco M.A.
      • Tepas 3rd, J.J.
      • Renfro W.H.
      • Vitarbo E.A.
      • Muehlberger M.
      The use of 23.4% hypertonic saline for the management of elevated intracranial pressure in patients with severe traumatic brain injury: a pilot study.
      J Trauma. 2009; 67 ([Epub 2009/08/12, PubMed PMID: 19667879]): 277-282https://doi.org/10.1097/TA.0b013e3181acc726
      ,
      • Nakagawa K.
      • Chang C.W.
      • Koenig M.A.
      • Yu M.
      • Tokumaru S.
      Treatment of refractory intracranial hypertension with 23.4% saline in children with severe traumatic brain injury.
      J Clin Anesth. 2012; 24 (Epub 2012/05/23) ([PubMed PMID: 22608588]): 318-323
      https://doi.org/10.1016/j.jclinane.2011.10.011
      ], IV bolus doses up to 24 ml per kilogram (ml/kg) [
      • Luu J.L.
      • Wendtland C.L.
      • Gross M.F.
      • Mirza F.
      • Zouros A.
      • Zimmerman G.J.
      • et al.
      Three-percent saline administration during pediatric critical care transport.
      Pediatr Emerg Care. 2011; 27 ([PubMed PMID: 22134236, Epub 2011/12/03]): 1113-1117https://doi.org/10.1097/PEC.0b013e31823aff59
      ], or with administration over 3 min [
      • Brenkert T.E.
      • Estrada C.M.
      • McMorrow S.P.
      • Abramo T.J.
      Intravenous hypertonic saline use in the pediatric emergency department.
      Pediatr Emerg Care. 2013; 29 ([Epub 2013/01/04, PubMed PMID: 23283268]): 71-73https://doi.org/10.1097/PEC.0b013e31827b54c3
      ,
      • Luu J.L.
      • Wendtland C.L.
      • Gross M.F.
      • Mirza F.
      • Zouros A.
      • Zimmerman G.J.
      • et al.
      Three-percent saline administration during pediatric critical care transport.
      Pediatr Emerg Care. 2011; 27 ([Epub 2011/12/03, PubMed PMID: 22134236]): 1113-1117https://doi.org/10.1097/PEC.0b013e31823aff59
      ,
      • Lumba-Brown A.
      • Harley J.
      • Lucio S.
      • Vaida F.
      • Hilfiker M.
      Hypertonic saline as a therapy for pediatric concussive pain: a randomized controlled trial in the emergency department.
      Pediatr Emerg Care. 2014; 30: 139-145
      ]. However, hypernatremia is a common side effect of continuous HTS infusion [
      • Khanna S.
      • Davis D.
      • Peterson B.
      • Fisher B.
      • Tung H.
      • O'Quigley J.
      • et al.
      Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in pediatric traumatic brain injury.
      Crit Care Med. 2000; 28 ([Epub 2000/05/16. PubMed PMID: 10809296]): 1144-1151
      ,
      • Peterson B.
      • Khanna S.
      • Fisher B.
      • Marshall L.
      Prolonged hypernatremia controls elevated intracranial pressure in head-injured pediatric patients.
      Crit Care Med. 2000; 28 ([Epub 2000/05/16. PubMed PMID: 10809295]): 1136-1143
      ] and serious adverse events have been reported when infusions are sustained over several days [
      • Gonda D.D.
      • Meltzer H.S.
      • Crawford J.R.
      • Hilfiker M.L.
      • Shellington D.K.
      • Peterson B.M.
      • et al.
      Complications associated with prolonged hypertonic saline therapy in children with elevated intracranial pressure.
      Pediatr Crit Care Med. 2013; 14 ([Epub 2013/07/05, PubMed PMID: 23823197]): 610-620https://doi.org/10.1097/PCC.0b013e318291772b
      ,
      • Froelich M.
      • Ni Q.
      • Wess C.
      • Ougorets I.
      • Hartl R.
      Continuous hypertonic saline therapy and the occurrence of complications in neurocritically ill patients.
      Crit Care Med. 2009; 37 ([Epub 2009/02/27, PubMed PMID: 19242317]): 1433-1441https://doi.org/10.1097/CCM.0b013e31819c1933
      ,
      • Hartl R.
      • Medary M.B.
      • Ruge M.
      • Arfors K.E.
      • Ghahremani F.
      • Ghajar J.
      Hypertonic/hyperoncotic saline attenuates microcirculatory disturbances after traumatic brain injury.
      J Trauma. 1997; 42 ([Epub 1997/05/01. PubMed PMID: 9191695]): S41-S47
      ,
      • Coimbra R.
      • Hoyt D.B.
      • Junger W.G.
      • Angle N.
      • Wolf P.
      • Loomis W.
      • et al.
      Hypertonic saline resuscitation decreases susceptibility to sepsis after hemorrhagic shock.
      J Trauma. 1997; 42 (discussion 6-7. [Epub 1997/04/01, PubMed PMID: 9137245]): 602-606
      ].

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        • Stein D.
        • Sheth K.N.
        Hypertonic saline and mannitol therapy in critical care neurology.
        J Intensive Care Med. Jan-Feb 2013; 28: 3-11
        View in Article
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        • Thomas D.
        • Peterson B.
        Hypertonic saline lowers raised intracranial pressure in children after head trauma.
        J Neurosurg Anesthesiol. 1992; 4: 4-10
        View in Article
        • Kochanek P.M.
        • Carney N.
        • Adelson P.D.
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        • Bell M.J.
        • Bratton S.
        • et al.
        Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents—second edition.
        Pediatr Crit Care Med. 2012; 13: S1-82https://doi.org/10.1097/PCC.0b013e31823f435c
        View in Article
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        Hypertonic saline lowers raised intracranial pressure in children after head trauma.
        J Neurosurg Anesthesiol. 1992; 4: 4-10
        View in Article
        • Berger Pelletier E.
        • Emond M.
        • Lauzier F.
        • Savard M.
        • Turgeon A.F.
        Hyperosmolar therapy in severe traumatic brain injury: a survey of emergency physicians from a large Canadian province.
        PLoS One. 2014; 9e95778
        View in Article
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        • Carney N.
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        Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents—second edition.
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        The use of 23.4% hypertonic saline for the management of elevated intracranial pressure in patients with severe traumatic brain injury: a pilot study.
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        • Tokumaru S.
        Treatment of refractory intracranial hypertension with 23.4% saline in children with severe traumatic brain injury.
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        Three-percent saline administration during pediatric critical care transport.
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        View in Article
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        • Abramo T.J.
        Intravenous hypertonic saline use in the pediatric emergency department.
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        View in Article
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        Hypertonic saline as a therapy for pediatric concussive pain: a randomized controlled trial in the emergency department.
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        View in Article
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        • Davis D.
        • Peterson B.
        • Fisher B.
        • Tung H.
        • O'Quigley J.
        • et al.
        Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in pediatric traumatic brain injury.
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        View in Article
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        • Marshall L.
        Prolonged hypernatremia controls elevated intracranial pressure in head-injured pediatric patients.
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        View in Article
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        • et al.
        Complications associated with prolonged hypertonic saline therapy in children with elevated intracranial pressure.
        Pediatr Crit Care Med. 2013; 14 ([Epub 2013/07/05, PubMed PMID: 23823197]): 610-620https://doi.org/10.1097/PCC.0b013e318291772b
        View in Article
        • Froelich M.
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        Continuous hypertonic saline therapy and the occurrence of complications in neurocritically ill patients.
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        Hypertonic/hyperoncotic saline attenuates microcirculatory disturbances after traumatic brain injury.
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        Hypertonic saline resuscitation decreases susceptibility to sepsis after hemorrhagic shock.
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      Article info

      Publication history

      Published online: September 28, 2018
      Accepted: September 25, 2018
      Received in revised form: September 24, 2018
      Received: September 10, 2018

      Identification

      DOI: https://doi.org/10.1016/j.ajem.2018.09.040

      Copyright

      © 2018 Elsevier Inc. All rights reserved.

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