Early continuous hypertonic saline infusion in patients with severe cerebrovascular disease

Objective: To study the safety and the effects of early continuous hypertonic saline infusion in patients with cerebral edema and underlying cerebrovascular disease. Design: Retrospective analysis. Setting: University medical center. Patients: Neurologic intensive care unit population with mixed cerebrovascular diseases. Interventions: None. Measurements and Main Results: Between May 2008 and December 2009, 100 patients with severe intracerebral hemorrhage, cerebral ischemia, or aneurysmal subarachnoid hemorrhage and signs of intracranial hypertension received within <= 72 hrs after symptom onset a continuous infusion of hypertonic saline (3%, target sodium 145-155 mmol/L, target osmolality 310-320 m0sm/kg) over 13 (4-23) days. We analyzed the frequency of episodes with elevated intracranial pressure (new anisocoria or intracranial pressure > 20 mm Hg for >= 20 mins), inhospital mortality, and the occurrence of adverse effects theoretically associated with hypertonic saline. The findings were compared with those of a historical control group (n = 115, 2007-2008) with equal underlying disease. In the treatment group, fewer episodes of critically elevated intracranial pressure (92 vs. 167, p =.027) in fewer patients (50 of 100 = 50.0% vs. 69 of 115 = 60.0% patients, p =.091) were observed, and inhospital mortality was significantly decreased (17.0% vs. 29.6%, p =.037). Adverse events, including cardiac arrhythmia, heart, liver or renal dysfunction, or pulmonary edema, occurred in both groups to a similar extent. Conclusions: Early and continuous infusion of hypertonic saline in patients with severe cerebrovascular disease and impending intracranial hypertension is safe and might reduce the frequency of intracranial pressure crises and mortality rate. A randomized controlled trial is warranted to confirm our findings and to evaluate the effects of hypertonic saline on functional outcomes. (Crit Care Med 2011; 39: 1766-1772)