Article Type : Research Article
Authors : Ahmed N Ghanem
Keywords : Fluid resuscitation; Hypertonic sodium therapy
Fluid resuscitation using hypertonic saline results in
volume expansion and less total infusion volume. It is a lifesaving therapy in
many acute clinical conditions. This may be of interest in oedematous patients
with intravascular volume depletion. When such strategies are employed, renal
effects may differ markedly according to prior intravascular volume status. In
hyper-volumetric states with depleted intravascular volume, hypertonic sodium
therapy of 5% NaCl and 8.4% NaCo3 turns it into hypervolemia with massive
diuretic effect. Hypertonic saline induced changes in serum osmolality and
sodium return to baseline within a limited period. Sparse evidence indicates
that resuscitation with hypertonic saline results in less perioperative
complications, ICU days and mortality in selected patients. In conclusion, the
use of hypertonic saline may have beneficial features in selected critically ill
patients when carefully chosen. Hypertonic sodium therapy of 5% NaCl and 8.4%
NaCo3 has proved lifesaving in treating the TUR syndrome, hyponatraemia and
ARDS. Further clinical studies assessing relevant clinical outcomes are
warranted.
Clinicians use hypertonic fluids to increase
intravascular fluid volume and restore blood pressure. Hypertonic saline can be
utilized in the treatment of hyponatremia. Hypertonic saline and mannitol are
both indicated to reduce intracranial pressure. Hypertonic saline is a
crystalloid intravenous fluid composed of NaCl dissolved in water with a higher
sodium concentration than normal blood serum. Both 3% and 5% hypertonic saline
(HS) is currently FDA-approved for use in hyponatremia and increased intracranial
pressure (ICP). Patients with hyponatremia with severe features should have
their serum sodium gradually corrected with boluses of hypertonic saline.
Patients should have their serum sodium monitored at regular intervals and can
receive multiple boluses a day [1]. Hypertonic saline increases the osmolality
of the blood, which allows fluid from the extravascular space to enter the
intravascular space, which leads to decreases in brain edema, improved cerebral
blood flow, and decreased CSF production. Research shows that 3% hypertonic
saline decreases ICP similarly to 20% mannitol [2]. Both hypertonic fluids have
similar effects on haemodynamic. Hypertonic saline leads to increases in serum
sodium and has less of a diuretic effect than mannitol, likely due to the
increased serum sodium causing ADH release. Hypertonic saline administered
after mannitol in traumatic brain injury has also demonstrated improvement of
cerebral oxygenation in addition to lowering ICP [3]. Due to there being no
guidelines regarding the administration of hypertonic saline for increased ICP,
various studies have used concentrations of 3% to 23.5% NaCl [4]. While not
FDA-approved, small doses of hypertonic saline are thought to be effective in
hypovolemia and shock due to fluid movement from the intracellular to
intravascular spaces, increasing intravascular fluid volume and improving
capillary blood flow [5]. Hypertonic fluids contain a higher concentration of
solute compared to plasma and interstitial fluid; this creates an osmotic gradient
and drives fluid from the interstitial space into the intravascular space. This
increase in intravascular volume increases mean arterial pressure (MAP), stroke
volume (SV), and cardiac output (CO) when compared with equal volumes of normal
saline or other isotonic fluids [6]. There is also a significant increase in
end-diastolic pressure and a subsequent decrease in pulmonary vascular
resistance. Hypertonic saline requires less overall volume administered to
achieve similar plasma volumes as larger volumes of normal saline [7].
Hypertonic saline stimulates vasopressin release from the pituitary gland,
which decreases water loss through the kidneys [8]. Hypertonic fluids are
administered parenterally via intravenous infusion. Infusion volumes and rates
depend on clinical indication
In patients with severe hyponatremia, serum sodium
should undergo correction by 4 to 6 mEq/L per day, which can be achieved with
100 mL boluses of 3% HS at 10-minute intervals up to three total boluses. Some
authorities recommend up to 8 mEq/L per day [9]. Less severe hyponatremia can
achieve control with enough hypertonic saline to manage symptoms [10]. Due to
the insufficient number of patients over age 65 in various trials, hypertonic
fluids should start at the lowest ends of the dosing scale in the geriatric
population. Paediatric traumatic brain injury generally receives treatment with
a 6.5 to 10 mL/kg bolus of hypertonic saline [11]. Administration via a
peripheral intravenous catheter is acceptable if no other access is available,
but central venous access is the preferred route.
There are no known specific contraindications for
hypertonic saline, according to the FDA. However, caution is necessary with
hypertonic saline in patients with congestive heart failure or renal
insufficiency due to their already increased fluid and sodium loads.
Hyponatraemia is the most common electrolyte disorder seen in clinical practice
and the consequences can range from minor symptoms to life-threatening
complications including seizures, coma and cardiorespiratory distress. These
effects occur as a result of fluid shifts due to deranged serum tonicity and
subsequent cerebral oedema. The appropriate assessment and management of
patients with hyponatraemia is not always achieved in clinical practice, which
is partly related to challenges in teaching with limited clinical guidance.
Recent evidence on the use of hypertonic sodium
therapy (HST) of 5%NaCl and 8.4%NaCo3
Hypertonic sodium therapy (HST) of 5%NaCl and 8.4%NaCo3
has proved lifesaving for treating the acute severe cases of the TUR syndrome,
acute dilution hyponatraemia and the acute respiratory distress syndrome
(ARDS).This HST was used successfully in treating the TUR syndrome, acute
dilution hyponatraemia of <120 mmol/l and ARDS in two clinical studies of a
23-cases series [12]. And a cohort prospective study on 100 TURP patients [13].
Among whom 10 developed the TUR syndrome with hyponatraemia of <120 mmol/l.
The studies demonstrated that two new types of cardiovascular shocks occur with
volumetric overload of sodium-free fluid (TYPE 1) and sodium-based fluids (TYPE
2) or volumetric overload shock (VOS 1) and volumetric overload shock (VOS 2)
[14]. Instantly hypertonic sodium corrects both shock and coma and brings the
patient back from near death. The treatment was given in bolus therapy of 200
ml alternating both fluids given over a period of 10 minutes and repeated after
rechecking serum sodium monitored by clinical improvement and urine output
[15]. More than 4 L of urine was excreted by the end of one hour period of
treatment matching a remarkable clinical recovery from shock and coma. The
effect of hypertonic sodium infusion on serum sodium and osmolality are shown
in (Figure 1).
Figure
1: Shows mean changes in measured serum
osmolality (OsmM) and calculated osmolality (OsmC) in patients with the TURP
syndrome comparing those infused with 5% hypertonic sodium (solid lines) and
those treated conservatively (slashed lines). OsmC was calculated from the
formula 2xNa+urea+glucose in mmol/l of serum concentration48 thus reflecting
changes in serum sodium concentration. The vertical dotted line represents the
start of operation (Time B) followed by C, C1, C2 (end of treatment) and D,
respectively.
Fluid resuscitation using hypertonic saline results in
volume expansion and less total infusion volume. This may be of interest in
oedematous patients with intravascular volume depletion. When such strategies
are employed, renal effects may differ markedly according to prior
intravascular volume status. Hypertonic saline induced changes in serum
osmolality and electrolytes return to baseline within a limited period. Sparse
evidence indicates that resuscitation with hypertonic saline results in less
perioperative complications, ICU days and mortality in selected patients. In
conclusion, the use of hypertonic saline may have beneficial features in
selected critically ill patients when carefully chosen. Further clinical
studies assessing relevant clinical outcomes are warranted.