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<< Therapeutic Uses Of Hypertonic Saline In The Critically Ill Emergency Department Patient (Trauma CME)

Controversies And Cutting Edge

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Controversies And Cutting Edge

Controversies And Cutting Edge

Hypertonic Saline And Hypotensive Resuscitation

In trauma patients, restoring intravascular volume and blood pressure in an attempt to achieve normal systemic pressure may cause further blood loss, dilutional coagulopathy, and increased mortality. This has led to an increasing emphasis on the concept of hypotensive resuscitation (ie, lowering resuscitation endpoints to an SBP of 80 to 90 mm Hg until definitive hemorrhage control can be achieved). This strategy has been shown to improve mortality for patients with penetrating trauma.69 While it is tempting to hope for a similar benefit in blunt trauma patients, the current literature has not demonstrated this.

This begs the question: Does the use of HTS work against this new resuscitative strategy? As discussed previously, HTS has been shown to increase MAP more than a similar volume of isotonic crystalloid solution, and some animal studies of uncontrolled hemorrhage have raised concern for increased bleeding after administration of HTS.71-75 In the largest study to date evaluating HTS for trauma patients in hemorrhagic shock, the HTS group had a higher earlier mortality and lower admission hemoglobin,48 which might have been caused by the artificially high MAP hiding the fact that the patient has organ hypoperfusion and delaying the recognition of shock by the emergency physician (and thereby delaying subsequent transfusion).

Hypertonic Saline For Sepsis

Due to its various effects at the systemic, organ, and microcirculatory levels, HTS appears to be a promising therapy in sepsis for improving tissue oxygenation and patient outcomes. To date, there are few prospective human trials that have studied HTS as a resuscitative fluid in sepsis. Those that have been performed showed an improvement in physiologic endpoints with HTS (increased cardiac output, decreased systemic vascular resistance, and increased pulmonary capillary wedge pressure), but they did not measure clinical outcomes.76-78

It is also theorized that, because of its immunomodulatory effects, HTS may help prevent the development of multiple organ failure in the septic patient. Thousands of patients with sepsis have been entered into various studies where different inflammatory mediators were blocked or modulated in the hope that HTS might alter outcome. Unfortunately, none of these have proven successful, and this author believes that it is doubtful that HTS will prove to have a beneficial patient effect secondary to these properties.

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