【Anesthesia Hotspot】Hypertonic saline resuscitation

Hypertonic saline resuscitation case format: Retrospective case analysis A 33-year-old male presented to the emergency room with closed traumatic brain injury and abdominal pain caused by a motor vehicle impact
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The patient was once unconscious at the time of the accident, but is now conscious and complains of neck and abdominal pain
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The patient had no special medical or surgical history, no medication, and no history of allergies
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Denied the use of tobacco, alcohol and drugs
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His vital signs were: blood pressure 90/60 mmHg, heart rate 110 beats/min, respiratory rate 24 beats/min, body temperature 36.
5°C
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Physical examination revealed predominantly positive somatic signs and left cranial nerve palsy
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Tenderness in the back of the neck, voiceless lungs on auscultation, distended abdomen, rebound tenderness, and disappearance of bowel sounds
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After infusion of 3L of normal saline at the accident scene and in the emergency room, laboratory test results were as follows: Hb 96g/L, WBC 13×109/L, Na+ 145mmol/L, K+ 3.
6mmol/L, HCO3- 18mmol/L, Cl - 110mmol/L, Creatinine 1.
4mg/dl, BUN 31mg/dl
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Paracentesis can draw bloody fluid
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Chest X-ray showed free air under the diaphragm
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CT of the head and neck revealed bilateral frontal lobe contusions and a medium-sized subdural hematoma in the right fronto-parietal lobe (Fig.
13.
1)
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Abdominal CT showed perforation of the cecum
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The patient underwent exploratory laparotomy, drainage of the subdural hematoma, extraventricular drainage, and monitoring of intracranial pressure
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The patient received an intravenous infusion of 6 L of normal saline, 500 ml of albumin, and 2 units of packed red blood cells
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Forty-eight hours after the operation, the patient remained in a coma, and CT of the brain showed diffuse cerebral edema
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On postoperative day 3, the patient developed oliguria and intra-abdominal pressure of 35 mmHg
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Figure 13.
1 Case Discussion of Right Frontoparietal Subdural Hematoma with Evidence of Ventricular Compression and Increased Intracranial Pressure , At the same time, attention should be paid to the amount and nature of the infusion fluid
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Given that the extracellular volume is 4 to 5 times the blood volume, trauma and burn patients must be given large volumes of isotonic crystalloids to maintain hemodynamic stability
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Trauma, burns, and major surgery will inevitably lead to a portion of the fluid entering the intracellular and tertiary spaces, thereby increasing the ratio of extracellular fluid to blood volume
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Progressive brain swelling, increased lung water, increased intra-abdominal pressure, and immune disturbances and microcirculatory dysfunction ensue
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The use of low-dose hypertonic saline can restore blood circulation and reduce the amount of fluid in the third space, thereby reducing the incidence of the above-mentioned serious events, and preventing and reducing the occurrence of cerebral edema, pulmonary edema, and abdominal compartment syndrome
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Traumatic brain injury After traumatic brain injury is often accompanied by cerebral edema and intracranial hypertension, such patients often have a poor prognosis
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Dehydration with mannitol remains a widely recommended treatment
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However, experimental data show that hypertonic saline (HTS) (3%, 7.
5%, 23.
4%) can effectively reduce intracranial pressure and maintain it for a longer time
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However, randomized population trials evaluating the effectiveness of hypertonic saline in patients with traumatic brain injury are still limited
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Vailet et al treated 20 patients with traumatic brain injury and refractory intracranial hypertension with 7.
5% HTS and mannitol, respectively, and found that HTS was more effective
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Cooper et al.
compared the use of 250ml 7.
5% HTS and lactated Ringer's solution in TBI patients and found that although the prognosis of the two groups was not different, the HTS group could maintain the increase in cerebral perfusion pressure for a longer period of time, which was consistent with the previous The experimental results are consistent
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Although laboratory and clinical trials have demonstrated that HTS is effective in reducing intracranial pressure, data demonstrating its efficacy in improving outcomes are lacking
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An obvious confounding factor was that the majority of study subjects suffered from multiple trauma at the same time, making it difficult to discern the underlying causes of morbidity and mortality
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Acute Lung Injury/Adult Respiratory Distress Syndrome/Immunomodulation Acute lung injury and adult respiratory distress syndrome occur in 40% of patients with multiple trauma
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Activated neutrophils in the pulmonary microcirculation of patients with trauma and hemorrhagic shock release a large number of inflammatory factors, which is an important factor causing secondary injury
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Laboratory studies have found that HTS can mediate immune regulation, thereby reducing inflammation
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Junge and Col-leagues found that in a murine model of hemorrhagic shock, HTS (7.
5% sodium chloride saline, 4 ml/kg) enhanced T cell function in vitro and cell-mediated immune function in vivo
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HTS also improved survival in animals with sepsis
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Rizoli et al.
compared the use of HTS and lactated Ringer's solution for resuscitation in a rodent model of hemorrhagic shock and found that HTS significantly reduced transpulmonary albumin leakage, neutrophil counts in bronchoalveolar lavage fluid and lung injury.
Degree of histopathology
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Secondary abdominal compartment syndrome Abdominal compartment syndrome refers to persistently increased intra-abdominal pressure ≥ 20 mmHg, with or without intra-abdominal perfusion pressure less than 50 mmHg, accompanied by new single or multiple organ failure
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Abdominal compartment syndrome can be primary from abdominal trauma and abdominal surgery, or secondary to visceral edema caused by massive fluid resuscitation in non-traumatic patients and burn patients, especially in shock patients
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The digestive tract is prone to ischemia-reperfusion injury, and the permeability of microvascular increases, resulting in a large amount of free fluid in the abdominal cavity and intra-abdominal hypertension
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Intra-abdominal hypertension and secondary abdominal compartment syndrome significantly reduce cardiac output by reducing preload and increasing systemic vascular resistance
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Intra-abdominal hypertension can also impair respiratory, renal, gastrointestinal, and liver functions, leading to multiple organ failure
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The massive crystalloid resuscitation used to alter the above pathophysiological changes often leads to the development of abdominal compartment syndrome and is referred to as "ineffective crystalloid preload"
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Studies have shown that the use of more than 6 L of crystalloid solution in the first 24 hours of volume resuscitation in critically ill patients leads to a high incidence of abdominal compartment syndrome and multiple organ failure
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In this regard, the use of HTS has obvious advantages in reducing the incidence of intra-abdominal hypertension
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Comparing hypertonic saline with standard lactated Ringer's solution in patients with burns greater than 40% of body surface area, Oda et al.
found that HTS significantly reduced the incidence of intra-abdominal hypertension and secondary abdominal compartment syndrome
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HTS was also found to improve oxygenation
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Despite these preliminary findings, further randomized controlled trials are needed before final recommendations for the use of HTS for the prevention of secondary abdominal compartment syndrome can be developed
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Types and methods of intravenous hypertonic saline The use of HTS during volume resuscitation can mobilize intracellular fluid, reduce cellular edema and reduce the total amount of fluid required
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Compared with isotonic crystalloid resuscitation, hypertonic saline resuscitation can more rapidly dilate blood volume, increase cardiac output, and improve oxygen transport
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The most commonly used hypertonic saline is 7.
5% sodium chloride and 6% dextran 70, a colloid with an osmotic pressure 2 to 3 times that of equal concentrations of human albumin
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HTS is safe and effective by infusion of 4–6 ml/kg over several hours
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Clinical studies have found that infusion of 250ml of 7.
5% sodium chloride solution within 10 to 15 minutes can also be well tolerated
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Table 13.
1 lists several commonly used HTS
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Table 13.
1 HTS characteristics HTS concentration (%) Na+/CI - (mmol/) osmotic pressure (mOsm/) Maximum infusion rate 35131030100ml/h58551710100ml/h7.
512822400250ml (bolus) 23.
440008000NA Complications of intravenous HTS hypertonic saline resuscitation Associated with hyperosmolarity and hypernatremia
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Plasma osmolality above 320 mOsm/L with mannitol can lead to acute renal failure; data on HTS and these complications are lacking
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Rapid correction of serum sodium concentration in hypotonic hyponatremia predisposes to pontine demyelination
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In retrospective studies, however, neither MRI nor autopsy detected central pontine demyelination
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Others argue that the use of HTS can lead to the development of reversible intracranial hypertension and hyperchloremic metabolic acidosis
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In conclusion, the use of HTS in the treatment of traumatic brain injury, multiple trauma and burn patients is a new concept; however, its application is limited due to the lack of relevant clinical research data
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The current randomized controlled trials will give us new perspectives on this treatment approach
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Key messages 1.
HTS is effective in treating traumatic brain injury by reducing intracranial pressure
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2.
A large number of crystalloid resuscitation may lead to secondary abdominal compartment syndrome, and the use of HTS can reduce the occurrence of secondary abdominal compartment syndrome
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3.
Complications of HTS use include hyperchloremic metabolic acidosis, hyperosmolarity, and reversible intracranial hypertension
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Question 1.
Which of the following complications will occur in patients with traumatic brain injury resuscitated with hypertonic saline? A.
Pontine demyelination B.
Cerebral edema C.
Cerebral vasospasm D.
Reversible intracranial hypertension E.
Diabetes insipidus Answer: D 2.
A 33-year-old male patient with a burn area of ​​50%, which is similar to isotonicity Which of the following physiological parameters is reduced when resuscitated with hypertonic saline compared with crystalloid resuscitation? A.
Intra-abdominal pressure B.
Pa02/Fi02 C.
Urine output D.
Cardiac output E.
Stomach pH Answer: A 3.
When resuscitating with a large amount of lactated Ringer's solution compared with resuscitation with a small amount of hypertonic saline, which of the following Are electrolyte disturbances more likely to occur? A.
hypomagnesemia B.
hypocalcemia C.
hypokalemia D.
hyponatremia E.
hypochloremia Answer: D