It is interesting that you brought this discussion into the group.If we
revisit the mechanism of ICP, the formula is CPP=MAP-ICP. Although the
upper limit of normal ICP is 15 mm Hg, the effective CPP in children and
infants has not been documented. Does an immature brain needs less CPP?
On the other hand when CPP falls below 40-50 mm Hg, ischemia occurs. It
is not known what minimal effective CPP is needed at a local level to
adequately perfuse the injured brain. The introduction of hypertonic
saline is based on the hypothesis to raise the serum osmolality which in
turn would raise the mean arterial pressure leading to increased
cerebral blood flow and eventually decreasing the cerebral edema. There
is some support of this in adult neurosurgical and anesthesiology
literature. I don't recall any published data in pediatric population.
Qureshi et al. in Critical Care Medicine published an interesting data
on this. They showed a reduction of mean ICP within the first 12 hrs.
correlating with an increase in the serum sodium conc. in head trauma
and post operative edema but not in patients with non traumatic
intracranial hemorrhage or cerebral infarction. But the beneficial
effect was short lasting. It is going to be a thought provoking
discussion, if at all there would be a benefit in starting hypertonic
saline in the emergency room in severe head trauma patients.
1. Schatzmann C. Heissler HE. Konig K. et al.Treatment of elevated head
intracranial pressure by infusion of 10% saline in severely head injured
patients. Acta Neurochirurgica- supplementum. 71: 31-3, 1998
2.Qureshi AI. Suarez JI et al. Use of hypertonic(3%) saline/acetate
infusion in the treatment of cerebral edema: Effect on intracranial
pressure pressure and lateral displacement of the brain. Critical Care
Medicine. 26(3):440-6, 1998 Mar.
Hope this helps.
Subhankar Bandyopadhyay, MD
Pediatric Emergency Medicine
Medical College of Wisconsin
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