Should the Hypotensive, Brain-Injured Patient Be Resuscitated with Hypertonic Solutions?
Hypertonic solutions appear promising for acute resuscitation of hypotensive, brain-injured patients. If the blood-brain barrier (BBB) is intact, movement of water between the brain and the intravascular space is highly dependent on osmotic gradients, which may be established by the administration of either hyper- or hypo-osmolar solutions. Acute bolus administration of hypertonic saline solutions decreases brain water in uninjured brain and decreases intracranial pressure (ICP) while temporarily increasing blood pressure and cardiac output. However, if the BBB is damaged, hypertonic saline will not decrease brain water or ICP. In head-injured children, 3% saline reduces ICP. In humans, acute resuscitation from hemorrhagic shock with hypertonic solutions (7.5% saline) is associated with improved outcome in multiply traumatized head-injured patients. However, some experimental studies fail to demonstrate benefit from hypertonic solutions. Insufficient data are currently available to justify the routine use of hypertonic fluids in hypotensive, brain-injured patients.
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