Comparison of Continuous Infusion of Hypertonic Saline to Intermittent Bolus Doses in the Management of Cerebral Edema: Time to reach the target serum sodium concentration.

Abstract

Abstract Background:Hypertonic saline (HTS) is frequently used for prevention and management of cerebral edema in patients with acute ischemic or hemorrhagic stroke and traumatic brain injury (TBI). Dosing of HTS remains variable. We compared efficacy of continuous infusion 3% hypertonic saline to intermittent bolus dosing in achieving target sodium concentration of ≥150 mmol/L. Methods: This retrospective study analyzed 673 patient encounters admitted to intensive care units (ICU) with acute ischemic or hemorrhagic stroke or TBI requiring 3% HTS between January 1, 2010, and December 31, 2019. Patients were divided into three groups, who received continuous infusion of HTS (≥ 6 hours), who received intermittent boluses of 150 ml (≥ 3 doses) and who received combination therapy non-concurrently. The primary outcome was reaching the target sodium goal of ≥150 mmol/L and the median time required to reach the goal. Secondary outcomes were occurrences of hyperchloremia (chloride >115 mmol/L) and hypernatremia (sodium >155 mmol/L), hospital and ICU length of stay and inpatient mortality. Results: About a quarter (26.9%) of intermittent bolus only encounters reached a sodium goal of ≥150 mmol/L compared to 52.6% of continuous infusion only and 74.3% of combination therapy group (p < .0001). The adjusted odds ratio (OR) for reaching the goal in continuous infusion group compared to intermittent bolus group was 2.94 (95% CI, 1.80-4.78; P < 0.0001). Among patients who reached the sodium goal, patients in the intermittent bolus only group reached it in a median (IQR) of 34.7 (19.7, 60.4) hours after HTS start, continuous infusion only patients reached it in a median (IQR) of 24.2 (17.0, 37.0) hours, and combination therapy group reached it in a median (IQR) of 28.7 (20.8, 41.6) hours. Increased occurrence of hypernatremia, hyperchloremia and in-patient mortality was noted in the continuous infusion group compared to intermittent bolus group. Conclusions: Use of continuous infusion of HTS was superior to intermittent bolus strategy in achieving target sodium levels. Although target sodium levels were achieved sooner with continuous HTS, there were higher rates of hyperchloremia and overshoot hypernatremia when compared to intermittent bolus strategy.