Treatment with hypertonic saline solutions

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Treatment with hypertonic saline solutions

• Øyvind Skraastad
• Barneanestesiteamet, Rikshospitalet
• Oslo

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20 years of research and clinical trials

• Hypertonic saline,7.5 NaCl (HS)
• Hypertonic saline/ 6 dextrane 70 (HSD)
• Hypertonic saline/ 6 HES 200/0.5 (HSS)

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Hypertonic saline

• Small volume - 4ml/kg
• Infusion in peripheral veins - no phlebitis
  observed
• Colloids added (dextrane,starch) improves
  volume-expansion - duration
• Acute hypovolemia and shock
• Mobilisation of extravasal fluid

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Hypertonic saline- experimental data and clinical
trials

• Experimental studies
• acute bleeding
• sepsis, burns
• increased intracranial pressure
• Clinical studies
• acute traumatology
• intraoperative hypovolemia, cardiac surgery

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Cardiac output
HSD Dextrane HS No volume resuscitation
Bleeding
Bolus inf.
hypotension
after infusion
baseline
minutes
Smith -89
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To be preferred in volume resucitation

• Hypertonic saline solutions should be
• Effective
• Increased intravascular volume, increased cardiac
  output
• Duration of effect
• Reduced mortality/morbidity
• Side effects/adverse effects negliable
• Price

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Transcapillary fluid transport
Pkap?
Starling -balance
NF K( Pkap -Pint ?int -?kap)
?int?
Pint?
P kap Intravascular hydrostatisk pressure P
int Extravasc hydrostatisk pressure ? kap
Intravascular colloid osmotisk pressure ? int
Intravasc. colloid osmotisk pressure
?kap?
ions
proteins
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Physiological effects

• Transcapillary Osmotic forces Increased
  plasma volume

1 mOsm excerts osmotisk pressure of 19,3 mmHg
Capillary leakage reduce the effect of
hypertonic saline, but still Absorbtive
force of 50 -200 mmHg (Colloids 2-4 mmHg)
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Osmotic transcapillary fluid transport

• Osmotic effects depends on
• permeability for each solute in different
  capillary beds
• number of particles on each side of the membrane
• Osmotic effects by
• few, large molecules with low permeability
• many, small particles with higher permeability

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Effects of hypertonic saline solutions

• Intravasation of fluid from extravascular space
  
• Peripheral vasodilatation
• Increased cardiac contractility
• Increased cardiac index

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Other effects

• Increased diuresis
• Reduced intracranail pressure
• Reduced endothelial edema, Reduced precapillary
  resistance and increased microcirculation
• Immunology ? (leucocyte adhesion, mediators of
  inflammation )

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Future of hypertonic saline solutions

• Effective fluid resucitation - rapid
  intravascular rehydration
• Fluid drug to reduce extravascular fluid in
  hypervolemia
• After cardiac surgery
• Intracranial hypertension

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Plasma volum increase
ml ekspansion ml infusion
Kramer et al. -89
Time
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Dilution by 4ml/kg HSDHealthy volunteers
? Plasmavol 7,6 ml/kg
Hb (g/100 ml)
? Plasmavol 9,7 ml/kg
HSD
Time (min)
Tølløfsrud et al.-98
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Distribution of fluid HSD 4 ml/kg(140ml)
minutter
Tølløfsrud et al. -00
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Distribution of fluid Ringer 25ml/kg (929 ml)
Tølløfsrud et al. -00
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Relative intravascular volume
HSD 4 ml/kg
ml expansion ml infusion
Ringer 25 ml/kg
Infusion
Tid (min)
Tølløfsrud et al.-00
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Relative volume-expansion-effect of HSD/Ringer
VEE ratio of HSD/Ringer
infusion
Time (min)
Tølløfsrud et al.-00
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Acute traumatology

• Effect in patients with multitrauma incl head
  trauma
• Reduced need for infusions
• Reduced need for transfusions
• No significant hypernatremia, coagulopathy
• But hyperchloremia

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Cardiac surgery Ex.corp circulation and capillary
leakage
Ex.vasc.space
Cell
Ringer
Blood
Lymph
Leakage 11-30 ml/min during ex.corp circulation
Koller et al. 1992 Fluid
overload at end op. 5,2 l Tølløfsrud
et al 1995
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• Fontanpatient with fluid overload.

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Diuresis and heart surgery
ml
Inf
Tølløfsrud et al. -98
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Fluid balance and heart surgery
ml
Infusion
Tølløfsrud et al. -98
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Hemodynamic data
CI
Inf.
Tølløfsrud et al. -98
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Open heart surgery

• Increased CI postoperatively
• Reduced SVR
• Reduced fluid overload after surgery
• But - increased preload - heart failure
• NB !Doses of fluid and rate of infusion

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Intracranial hypertension

• Continously high sodium values (145-160 mmol/l)
  may reduce elevated ICP when conventional
  treatment fails
• Reduce transcapillary leak in pathological brain
  tissue (trauma, tumor, ischemia) ?
• Reduce extravascular fluid in areas with normal
  blood-brain-barrier

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Clinical use of hypertonic saline solutions

• Optimal dose ?
• Optimal rate of infusion ?
• Dose bolus 4 ml/kg 5-20 minutes.
• NB !
• Volume sensitive patients
• vasodilatation
• changes in Na- concentration

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Conclusion

• Safe and effective treatment of hypovolemia
• Effective treatment of extravascular fluid
  overload ?
• Beneficial for patients with elevated ICP ?

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