Cerebrovascular Effects of Hypertonic Resuscitation

  • D. S. Prough
  • D. S. De Witt
Conference paper
Part of the Yearbook of Intensive Care and Emergency Medicine book series (YEARBOOK, volume 1992)

Abstract

Intravenous fluids vary in oncotic pressure, osmolarity, and tonicity. Osmotically active particles attract water across semipermeable membranes until equilibrium is attained. The osmolarityof a solution, which quantifies the forces determining the distribution of water, refers to the number of osmotically active particles per liter of solution. In contrast, osmolalityis a measurement of the number of osmotically active particles per kilogramof solvent. The osmolality of body fluids can be estimated as follows:
$${\rm{osmolality = ([N}}{{\rm{a}}^ + }]\,\, \times \,\,2)\,\, + \,({\rm{glucose}}\, \div \,18)\, + \,({\rm{BUN}}\, \div \,2.3)$$
where [Na + ] is expressed in mEq 1−1, serum glucose is expressed in mg-dl−1, and BUN is expressed in mg-dl−1 respectively. Urea, sugars, alcohols, and radiographic dyes that increase osmolality may increase the measured value, generating an increased “osmolal gap” between the calculated and measured values. Osmotic activity can also be expressed in terms of osmotic pressure, a measure of the attraction for water exerted across a semipermeable membrane. Osmotic pressure is approximated from the equation [1]:
$${\rm{Osmotic}}\,{\rm{pressure}}\,{\rm{(mm}}\,{\rm{Hg)}}\,{\rm{ = }}\,{\rm{19}}{\rm{.3}}\,{\rm{ \times }}\;{\rm{Osmolality}}\;{\rm{(mOsm/kg)}}$$
A hyperosmolar state occurs whenever the concentration of osmotically active particles is high. Thus, uremia (increased BUN) and hypernatremia (increased serum sodium) increase both serum osmolality and osmolarity. However, because urea distributes throughout total body water, an increase in BUN, unlike an increase in [Na + ], does not cause hypertonicity, i.e. osmotically mediated redistribution of water from intracellular volume (ICV) to extracellular volume (ECV). The term “tonicity” is also used colloquially to compare the osmotic pressure of a solution to that of plasma. A fluid in which the osmotic pressure is similar to that of plasma; is termed isotonic. Hypotonie solutions exert lower osmotic pressures than plasma; hypertonic solutions exert higher osmotic pressures (Table 1).

Keywords

Sugar Permeability Catheter Albumin Urea 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Guyton AC (1981) Textbook of Medical Physiology, 6th edn. WB Saunders, PhiladelphiaGoogle Scholar
  2. 2.
    Zornow MH, Todd MM, Moore SS (1987) The acute cerebral effects of changes in plasma osmolality and oncotic pressure. Anesthesiology 67:936–941PubMedCrossRefGoogle Scholar
  3. 3.
    Tommasino C, Moore S, Todd MM (1988) Cerebral effects of isovolemic hemodilution with crystalloid or colloid solutions. Crit Care Med 16:862–868PubMedCrossRefGoogle Scholar
  4. 4.
    Poole GV Jr, Prough DS, Johnson JC, Stullken EH, Stump DA, Howard G (1987) Effects of resuscitation from hemorrhagic shock on cerebral hemodynamics in the presence of an intracranial mass. J Trauma 27:18–23PubMedCrossRefGoogle Scholar
  5. 5.
    Maningas PA, De Guzman LR, Tillman FJ, et al. (1986) Small-volume infusion of 7.5 NaCl in 6% Dextran 70 for the treatment of severe hemorrhagic shock in swine. Ann Emerg Med 15:1131–1137PubMedCrossRefGoogle Scholar
  6. 6.
    Weed LH, McKibben PS (1919) Experimental alteration of brain bulk. Am J Physiol 48:531–561Google Scholar
  7. 7.
    Wilson BJ, Jones RF, Coleman ST, Moyer CA (1951) The effects of various hypertonic sodium salt solutions on asternal pressure. Surgery 30:361–366PubMedGoogle Scholar
  8. 8.
    Baue AE, Tragus ET, Parkins WM (1967) Effects of sodium chloride and bicarbonate in shock with metabolic acidosis. Am J Physiol 212:54–60PubMedGoogle Scholar
  9. 9.
    Jelenko C III, Wiiliams JB, Wheeler ML, et al. (1979) Studies in shock and resuscitation. I. Use of a hypertonic, albumin-containing fluid demand regimen (HALFD) in resuscitation. Crit Care Med 7:157–167PubMedCrossRefGoogle Scholar
  10. 10.
    Monafo WW, Chuntrasakul C, Ayvazian VH (1973) Hypertonic sodium solutions in the treatment of burn shock. Am J Surg 126:778–783PubMedCrossRefGoogle Scholar
  11. 11.
    Monafo WW (1970) The treatment of burn shock by the intravenous and oral administration of hypertonic lactated saline solution. J Trauma 10:575–586PubMedCrossRefGoogle Scholar
  12. 12.
    Liang CS, Hood WB Jr (1978) Mechanism of cardiac output response to hypertonic sodium chloride infusion in dogs. Am J Physiol 235:18–22Google Scholar
  13. 13.
    Shackford SR, Sise MJ, Fridlund PH, et al. (1983) Hypertonic sodium lactate versus lactated Ringer’s solution for intravenous fluid therapy in operations on the abdominal aorta. Surgery 94:41–51PubMedGoogle Scholar
  14. 14.
    Velasco IT, Pontieri V, Rocha e Silva MR Jr, Lopes OU (1980) Hyperosmotic NaCl and severe hemorrhagic shock. Am J Physiol 239:664–673Google Scholar
  15. 15.
    Layon J, Duncan D, Gallagher TJ, Banner MJ (1987) Hypertonic saline as a resuscitation solution in hemorrhagic shock: Effects on extravascular lung water and cardiopulmonary function. Anesth Analg 66:154–158PubMedCrossRefGoogle Scholar
  16. 16.
    Ljungqvist O, Boija PO, Ware J (1989) The effect of hyperosmolar infusions on survival after hemorrhage. Acta Chir Scand 155:433–438PubMedGoogle Scholar
  17. 17.
    Lopes OU, Pontieri V, Rocha e Silva MR Jr, Velasco IT (1981) Hyperosmotic NaCl and severe hemorrhagic shock: Role of the innervated lung. Am J Physiol 241:883–890Google Scholar
  18. 18.
    Younes RN, Aun F, Tomida RM, Birolini D (1985) The role of lung innervation in the he-modynamic response to hypertonic sodium chloride solutions in hemorrhagic shock. Surgery 98:900–906PubMedGoogle Scholar
  19. 19.
    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
  20. 20.
    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
  21. 21.
    Onarheim H, Missavage AE, Kramer GC, Gunther RA (1990) Effectiveness of hypertonic saline-dextran 70 for initial fluid resuscitation of major burns. J Trauma 30:597–603PubMedCrossRefGoogle Scholar
  22. 22.
    Gunn ML, Hansbrough JF, Davis JW, Furst SR, Field TO (1989) Prospective, randomized trial of hypertonic sodium lactate versus lactated Ringer’s solution for burn shock resuscitation. J Trauma 29:1261–1267PubMedCrossRefGoogle Scholar
  23. 23.
    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
  24. 24.
    Johnston WE, Alford PT, Prough DS, Howard G, Royster RL (1985) Cardiopulmonary effects of hypertonic saline in canine oleic acid-induced pulmonary edema. Crit Care Med 13:814–817PubMedCrossRefGoogle Scholar
  25. 25.
    Boldt J, Kling D, Herold C, Dapper F, Hempelmann G (1990) Volume therapy with hypertonic saline hydroxyethyl starch solution in cardiac surgery. Anaesthesia 45:928–934PubMedCrossRefGoogle Scholar
  26. 26.
    Smith GJ, Kramer GC, Perron P, Nakayama S, Gunther RA, Holcroft JW (1985) A comparison of several hypertonic solutions for resuscitation of bled sheep. J Surg Res 39:517–528PubMedCrossRefGoogle Scholar
  27. 27.
    Vassar MJ, Perry CA, Holcroft JW (1990) Analysis of potential risks associated with 7.5% sodium chloride resuscitation of traumatic shock. Arch Surg 125:1309–1315PubMedCrossRefGoogle Scholar
  28. 28.
    Todd MM, Tommasino C, Moore S (1985) Cerebral effects of isovolemic hemodilution with a hypertonic saline solution. J Neurosurg 63:944–948PubMedCrossRefGoogle Scholar
  29. 29.
    Prough DS, Johnson JC, Poole GV Jr, Stullken EH, Johnston WE, Royster R (1985) Effects in intracranial pressure of resuscitation from hemorrhagic shock with hypertonic saline versus lactated Ringer’s solution. Crit Care Med 13:407–411PubMedCrossRefGoogle Scholar
  30. 30.
    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
  31. 31.
    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
  32. 32.
    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
  33. 33.
    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
  34. 34.
    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
  35. 35.
    Gunnar WP, Merlotti GJ, Barrett J, Jonasson O (1986) Resuscitation from hemorrhagic shock: Alterations of the intracranial pressure after normal saline, 3% saline and dextran-40. Ann Surg 204:686–692PubMedCrossRefGoogle Scholar
  36. 36.
    Prough DS, De Witt DS, Taylor CL, Deal DD, Vines SM (1991) Hypertonic saline does not reduce intracranial pressure or improve cerebral blood flow after experimental head injury and hemorrhage in cats. Anesthesiology 75:A544CrossRefGoogle Scholar
  37. 37.
    Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS (1988) Prospective trial of supra-normal values of survivors as therapeutic goals in high-risk surgical patients. Chest 94:1176–1186PubMedCrossRefGoogle Scholar
  38. 38.
    Whitley JM, Prough DS, Brockschmidt JK, Vines SM, De Witt DS (1991) Cerebral hemody-namic effects of fluid resuscitation in the presence of an experimental intracranial mass. Surgery 110:514–522PubMedGoogle Scholar
  39. 39.
    Miller JD, Butterworth JF, Guideman SK, et al. (1981) Further experience in the management of severe head injury. J Neurosurg 54:289–299PubMedCrossRefGoogle Scholar
  40. 40.
    Shackford SR, Fortlage DA, Peters RM, Hollingsworth-Fridlund P, Sise MJ (1987) Serum osmolar and electrolyte changes associated with large infusions of hypertonic sodium lactate for intravascular volume expansion of patients undergoing aortic reconstruction. Surg Gyne-col Obstet 164:127–136Google Scholar
  41. 41.
    Norenberg MD, Leslie KO, Robertson AS (1982) Association between rise in serum sodium and central pontine myelinolysis. Ann Neurol 11:128–135PubMedCrossRefGoogle Scholar
  42. 42.
    Laureno R (1983) Central pontine myelinolysis following rapid correction of hyponatremia. Ann Neurol 13:232–242PubMedCrossRefGoogle Scholar
  43. 43.
    Norenberg MD, Papendick RE (1984) Chronicity of hyponatremia as a factor in experimental myelinolysis. Ann Neurol 15:544–547PubMedCrossRefGoogle Scholar
  44. 44.
    Mazzoni MC, Borgstrom P, Arfors KE, Intaglietta M (1990) The efficacy of iso-and hyper-osmotic fluids as volume expanders in fixed-volume and uncontrolled hemorrhage. Ann Emerg Med 19:350–358PubMedCrossRefGoogle Scholar
  45. 45.
    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
  46. 46.
    Prough DS, Johnston WE: Fluid resuscitation in septic shock: No solution yet. Anesth Analg 1989; 69:699Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 1992

Authors and Affiliations

  • D. S. Prough
  • D. S. De Witt

There are no affiliations available

Personalised recommendations