NEUROICU Guideline: Osmotherapy for Treatment of Intracranial Hypertension Hypertonic Saline- 3% NaCl - PDF Document

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  1. Intracranial Hypertension: 3%NaCl Last reviewed: 5/30/06 NEUROICU Guideline: Osmotherapy for Treatment of Intracranial Hypertension Hypertonic Saline- 3% NaCl Goal:To maintain therapeutic serum osmolality in severely brain-injured patients refractory to 5%NaCl Patient Eligibility: 1. Patient must be in the NeuroICU and administration of therapy must be per protocol. 2. Patient must have severe intracranial hypertension (ICP>20mmHg) 3.At least one of the following criteria must be met (see NeuroICU Mannitol algorithm a.Mannitol failure: mannitol has failed to lower ICP to less than 20mmHg within 20 minutes of administration b.Mannitol is contraindicated: i.Serum osmolar gap>20 ii.Mannitol has been administered within the past 6 hrs iii.Mannitol is associated with a drop in CPP<70mmHg iv.Significant intravascular volume depletion exists: Based on a clinical assessment by the NeuroCritical Care Service which synthesizes exam findings, laboratory results, and other pertinent clinical data For example: CVP<6; net negative fluid balance; elevated BUN/creatinine ratio 4.There must be a failure of 5%NaCl to lower ICP: a.20 minutes after administration of 5%NaCl- ICP remains above 20mmHg OR b.Severe intracranial hypertension (ICP>20mmHg) recurs within 4 hrs of administration of 5%NaCl Contraindications: 1.ICP < 20 mmHg 2.Severe CHF a. Hypoxia due to pulmonary edema b. Pink, frothy secretions c. Severe pulmonary edema on CXR 3.Significant volume overload: a. Based on a clinical assessment by the NeuroCritical Care Service which synthesizes exam findings, laboratory results, and other pertinent clinical data b. Use caution if CVP >15 mmHg or PAOP >12 mmHg 4.Serum Na+ >160mmol/L 5.Chronic hyponatremia 6.Diabetes Insipidus (DI) 7.Relative Contraindication: Primary intracerebral hemmorhage

  2. Intracranial Hypertension: 3%NaCl Last reviewed: 5/30/06 Monitoring: All patient receiving HTS for the treatment of intracranial hypertension must have the following parameters monitored and documented: 1.Central venous pressure via a central venous catheter OR pulmonary artery occlusion pressure via a pulmonary artery catheter 2.Intracranial pressure monitoring 3.Serum Na+ every 2 hrs 4.All other monitoring and documentation per NeuroICU protocol Protocol: ** Use must be approved by Neurocritical Care Attending ** HTS must be infused into a central venous catheter. 1.STAT serum Na+ must be checked and recorded under the following conditions: a.Last serum Na+ value was obtained > 2 hrs prior to planned HTS administration OR b.Mannitol or 5%NaCl has been administered since the last serum Na+ value was obtained. 2.If ICP>20mmHg AND Na+<160 mmol/L AND all of the above criteria are met, patient is eligible to receive 3%NaCl 3.Start infusion of 3%NaCl: a.MD will order a continuous 3%NaCl infusion to be started at a rate of 10- 50ml/hr and titrated q2hrs per sliding scale to achieve a target serum sodium level that will be <160mmol/L b.Serum Na+ levels must be checked every 2 hours during infusion c.Neither boluses of mannitol nor 5%NaCl should be administered during therapy with 3%NaCl d.Sliding Scale: Serum Na+ ICP >20 Increase rate by 20ml/hr not to exceed 100ml/hr. <140 <20 Continue current rate >20 Increase rate by 10ml/hr not to exceed 100ml/hr. 141-150 <20 Continue current rate >20 Increase rate by 5ml/hr not to exceed 100ml/hr. 151-160 <20 Continue current rate > 160 Stop infusion; recheck serum Na+ in 2 hrs. Call MD. e.Treatment endpoints: Treatment should continue until either i.Causes of intracranial hypertension have been resolved or have been more definitively treated ii.Signs/Symptoms of volume overload or CHF. Daily assessment and documentation regarding the necessity of ongoing treatment is necessary. f.Infusion must be discontinued if serum Na+ >160 mmol/L g.Infusion must be stopped if signs/symptoms of volume overload develop. 3% NaCl Rate