Should the Hypotensive, Brain-Injured Patient Be Resuscitated with Hypertonic Solutions?

  • D. S. Prough
  • M. H. Zornow
  • D. S. DeWitt
Conference paper


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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  1. 1.
    Weed LH, McKibben PS (1919) Experimental alteration of brain bulk. Am J Physiol 48:531–558Google Scholar
  2. 2.
    Tanno H, Nockels RP, Pitts LH, Noble LJ (1992) Breakdown of the blood-brain barrier after fluid percussive brain injury in the rat. Part 1: distribution and time course of protein extravasation. J Neurotrauma 9:335–347PubMedCrossRefGoogle Scholar
  3. 3.
    Shenkin HA, Goluboff B, Haft H (1964) Further observations on the effects of abruptly increased osmotic pressure of plasma on cerebrospinal-fluid pressure in man. J Neurosurg 22:563–568CrossRefGoogle Scholar
  4. 4.
    Todd MM, Tommasino C, Moore S (1985) Cerebral effects of isovolemic hemodilution with a hypertonic saline solution. J Neurosurg 63:944–948PubMedCrossRefGoogle Scholar
  5. 5.
    Gunnar W, Jonasson O, Merlotti G, Stone J, Barrett J (1988) Head injury and hemorrhagic shock: studies of the blood brain barrier and intracranial pressure after resuscitation with normal saline solution, 3% saline solution, and dextran-40. Surgery 103:398–407PubMedGoogle Scholar
  6. 6.
    Gunner WP, Merlotti GJ, Jonasson O, Barrett J (1986) Resuscitation from hemorrhagic shock: alterations of the intracranial pressure after normal saline, 3% saline and dextran-40. Ann Surg 204:686–692CrossRefGoogle Scholar
  7. 7.
    Shackford SR, Zhuang J, Schmoker J (1992) Intravenous fluid tonicity: effect on intracranial pressure, cerebral blood flow, and cerebral oxygen delivery in focal brain injury. J Neurosurg 76:91–98PubMedCrossRefGoogle Scholar
  8. 8.
    Schertel ER, Valentine AK, Rademakers AM, Muir WW (1990) Influence of 7% NaCl on the mechanical properties of the systemic circulation in the hypovolemic dog. Circ Shock 31:203–214PubMedGoogle Scholar
  9. 9.
    Spital A, Sterns RD (1989) The paradox of sodium’s volume of distribution. Why an extracellular solute appears to distribute over total body water. Arch Intern Med 149:1255–1257PubMedCrossRefGoogle Scholar
  10. 10.
    Worthley LIG, Cooper DJ, Jones N (1988) Treatment of resistant intracranial hypertension with hypertonic saline. Report of two cases. J Neurosurg 68:478–481PubMedCrossRefGoogle Scholar
  11. 11.
    Fisher B, Thomas D, Peterson B (1992) Hypertonic saline lowers raised intracranial pressure in children after head trauma. J Neurosurg Anesthesiol 4:4–10PubMedCrossRefGoogle Scholar
  12. 12.
    Zornow MH, Scheller MS, Shackford SR (1989) Effect of a hypertonic lactated Ringer’s solution on intracranial pressure and cerebral water content in a model of traumatic brain injury. J Trauma 29:484–488PubMedCrossRefGoogle Scholar
  13. 13.
    Scheller MS, Zornow MH, Oh YS (1991) A comparison of the cerebral and hemodynamic effects of mannitol and hypertonic saline in a rabbit model of acute cryogenic brain injury. J Neurosurg Anesthesiol 3:291–296PubMedCrossRefGoogle Scholar
  14. 14.
    Sotos JF, Dodge PR, Meara P, Talbot NB (1960) Studies in experimental hypertonicity. I: Pathogenesis of the clinical syndrome, biochemical abnormalities and cause of death. Pediatrics 26:925–938Google Scholar
  15. 15.
    Sterns RH, Riggs JE, Schochet SS Jr (1986) Osmotic demyelination syndrome following correction of hyponatremia. N Engl J Med 314:1535–1542PubMedCrossRefGoogle Scholar
  16. 16.
    Kleinschmidt-DeMasters K, Norenberg MD (1981) Rapid correction of hyponatremia causes demyelination: relation to central pontine myelinolysis. Science 211:1068–1070PubMedCrossRefGoogle Scholar
  17. 17.
    Arieff AI (1986) Hyponatremia, convulsions, respiratory arrest, and permanent brain damage after elective surgery in healthy women. N Engl J Med 314:1529–1535PubMedCrossRefGoogle Scholar
  18. 18.
    Vassar MJ, Perry CA, Gannaway WL, Holcroft JW (1991) 7.5% sodium chloride/dextran for resuscitation of trauma patients undergoing helicopter transport. Arch Surg 126:1065–1072PubMedCrossRefGoogle Scholar
  19. 19.
    Gross D, Landau EH, Klin B, Krausz MM (1990) Treatment of uncontrolled hemorrhagic shock with hypertonic saline solution. Surg Gynecol Obstet 170:106–112PubMedGoogle Scholar
  20. 20.
    Bickell WH, Wall MJ, Jr., Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL (1994) Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 331:1105–1109PubMedCrossRefGoogle Scholar
  21. 21.
    Wilson BJ, Jones RF, Coleman ST, Moyer CA (1951) The effects of various hypertonic sodium salt solutions on cisternal pressure. Surgery 30:361–366PubMedGoogle Scholar
  22. 22.
    McManus ML, Strange K (1993) Acute volume regulation of brain cells in response to hypertonic challenge. Anesthesiology 78:1132–1137PubMedCrossRefGoogle Scholar
  23. 23.
    Hino A, Ueda S, Mizukawa N, Imahori Y, Tenjin H (1992) Effect of hemodilution on cerebral hemodynamics and oxygen metabolism. Stroke 23:423–426PubMedCrossRefGoogle Scholar
  24. 24.
    Prough DS, Johnson JC, Stump DA, Stullken EH, Poole GV Jr, Howard G (1986) Effects of hypertonic saline versus lactated Ringer’s solution on cerebral oxygen transport during resuscitation from hemorrhagic shock. J Neurosurg 64:627–632PubMedCrossRefGoogle Scholar
  25. 25.
    Prough DS, Johnson JC, Poole GV, Jr., Stullken EH, Johnston WE, Royster R (1985) Effects on intracranial pressure of resuscitation from hemorrhagic shock with hypertonic saline versus lactated Ringer’s solution. Crit Care Med 13:407–411PubMedCrossRefGoogle Scholar
  26. 26.
    Schmoker JD, Zhuang J, Shackford SR (1991) Hypertonic fluid resuscitation improves cerebral oxygen delivery and reduces intracranial pressure after hemorrhagic shock. J Trauma 31:1607–1613PubMedCrossRefGoogle Scholar
  27. 27.
    Whitley JM, Prough DS, Taylor CL, Deal DD, DeWitt DS (1991) Cerebrovascular effects of small volume resuscitation from hemorrhagic shock: comparison of hypertonic saline and concentrated hydroxethyl starch in dogs. J Neurosurg Anesthesiol 3:(l):47–55PubMedCrossRefGoogle Scholar
  28. 28.
    Prough DS, Whitley JM, Olympio MA, Taylor CL, DeWitt DS (1991) Hypertonic hyperoncotic fluid resuscitation after hemorrhagic shock in dogs. Anesth Analg 73:738–744PubMedGoogle Scholar
  29. 29.
    Prough DS, Whitley JM, Taylor CL, Deal DD, De Witt DS (1991) Regional cerebral blood flow following resuscitation from hemorrhagic shock with hypertonic saline: Influence of a subdural mass. Anesthesiology 75:319–327PubMedCrossRefGoogle Scholar
  30. 30.
    Gunnar W, Kane J, Barrett J (1989) Cerebral blood flow following hypertonic saline resuscitation in an experimental model of hemorrhagic shock and head injury. Braz J Med Biol Res 22:287–289PubMedGoogle Scholar
  31. 31.
    Ducey JP, Mozingo DW, Lamiell JM, Okerburg C, Gueller GE (1989) A comparison of the cerebral and cardiovascular effects of complete resuscitation with isotonic and hypertonic saline, hetastarch, and whole blood following hemorrhage. J Trauma 29:1510–1518PubMedCrossRefGoogle Scholar
  32. 32.
    Whitley JM, Prough DS, Brockschmidt JK, Vines SM, DeWitt DS (1991) Cerebral hemodynamic effects of fluid resuscitation in the presence of an experimental intracranial mass. Surgery 110:514–522PubMedGoogle Scholar
  33. 33.
    Warner DS, Boehland LA (1988) Effects of iso-osmolal intravenous fluid therapy on postischemic brain water content in the rat. Anesthesiology 68:86–91PubMedCrossRefGoogle Scholar
  34. 34.
    Walsh JC, Zhuang J, Shackford SR (1991) A comparison of hypertonic to isotonic fluid in the resuscitation of brain injury and hemorrhagic shock. J Surg Res 50:284–292PubMedCrossRefGoogle Scholar
  35. 35.
    Battistella FD, Wisner DH (1991) Combined hemorrhagic shock and head injury: effects of hypertonic saline (7.5%) resuscitation. J Trauma 31:182–188PubMedGoogle Scholar
  36. 36.
    Wisner DH, Busche F, Sturm J, Gaab M, Meyer H (1989) Traumatic shock and head injury: effects of fluid resuscitation on the brain. J Surg Res 46:49–59PubMedCrossRefGoogle Scholar
  37. 37.
    Wisner DH, Schuster L, Quinn C (1990) Hypertonic saline resuscitation of head injury: effects on cerebral water content. J Trauma 30:75–78PubMedCrossRefGoogle Scholar
  38. 38.
    DeWitt DS, Prough DS, Taylor CL, Deal DD, Vines SM (1996) Hypertonic saline does not improve cerebral oxygen delivery after head injury and mild hemorrhage in cats. Crit Care Med 24:109–117PubMedCrossRefGoogle Scholar
  39. 39.
    Mattox KL, Maningas PA, Moore EE, Mateer JR, Marx JA, Aprahamian C, Burch JM, Pepe PE (1991) Prehospital hypertonic saline/dextran infusion for post-traumatic hypotension. The U.S.A. Multicenter Trial. Ann Surg 213:482–491PubMedCrossRefGoogle Scholar
  40. 40.
    Vassar MJ, Fischer RP, O’Brien PE, Bachulis BL, Chambers JA, Hoyt DB, Holcroft JW (1993) A multicenter trial for resuscitation of injured patients with 7.5% sodium chloride: The effect of added dextran 70. Arch Surg 128:1003–1013PubMedCrossRefGoogle Scholar
  41. 41.
    Wilson BJ, Jones RF, Coleman ST, Moyer CA (1958) The effects of various hypertonic sodium salt solutions on cisternal pressure. Surgery 30:361Google Scholar
  42. 42.
    Smith SD, Cone JB, Bowser BH, Caldwell FT (1982) Cerebral edema following acute hemorrhage in a murine model: the role of crystalloid resuscitation. J Trauma 22:(7):588–590PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 1997

Authors and Affiliations

  • D. S. Prough
  • M. H. Zornow
  • D. S. DeWitt

There are no affiliations available

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