hypertonic saline for impending herniation

The article on the beneficial effects of 3% Na on CT midline shift was based on
simple clinical findings - serum Na and Ct scan. **Qureshi AI, Suarez JI,
Bhardwaj A, Mirski M, Schnitzer MS, Hanley DF, Ulatowski JA.
Use of hypertonic (3%) saline/acetate infusion in the treatment of cerebral
edema: Effect on intracranial pressure and lateral displacement of the
brain.Crit Care Med. 1998 Mar;26(3):440-6

The first article on 23.4% and refractory - used clinical clinical exam, common
ICP monitors (bolts and ventric drain) and typical lab Na). **Suarez JI, Qureshi
AI, Bhardwaj A, Williams MA, Schnitzer MS, Mirski M, Hanley DF, Ulatowski
JA.Treatment of refractory intracranial hypertension with 23.4% saline. Crit
Care Med. 1998 Jun;26(6):1118-22

Among the report on functional outcome after reversal of transtentorial
herniation with brain resuscitation (including - use hypertonic saline) used GCS
and pupils and common clinical parameters. **Qureshi AI, Geocadin RG, Suarez JI,
Ulatowski JA.Long-term outcome after medical reversal of transtentorial
herniation in patients with supratentorial mass lesions.Crit Care Med. 2000
May;28(5):1556-64.

And recently, the use of 23.4% Na bolus to reverse transtentorial herniation -
was again based on bedside clinical finding of GCS change, pupillary size and
light reactivity, serum Na monitoring. **Koenig MA, Bryan M, Lewin JL 3rd,
Mirski MA, Geocadin RG, Stevens RD. Reversal of transtentorial herniation with
hypertonic saline. Neurology. 2008 Mar 25;70(13):1023-9. Epub 2008 Feb 13.

Hypertonic saline is readily available and seems to be very beneficial (yes I
understand that we lack level 1 RCT); it maybe even be better than mannitol and
it helped us realize that the dreadful event of transtentorial herniation is
reversible and survivable. So we must do our best to make this treatment
available in as many ICUs and appropriate patients as possible.

Certainly, we should encourage more research to understand this problem and the
use of LICOX or other similar technologies is a promising direction. It is great
that many top centers are using this as a research or adjunct tool but until
more definite data comes, I believe that these devices should not be made to
define or limit the care we provide.

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