Critical Care: Critical Care in the ICU |

Protocol for Administration of Hypertonic Saline in Medical Intensive Care Patients With Severe Stroke FREE TO VIEW

Robert Stewart, MD; Shekhar Ghamande, MD; Heath White; Jennifer Rasmussen, MD; Leigh Allen
Author and Funding Information

Baylor Scott & White, Temple, TX

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):230A. doi:10.1016/j.chest.2016.08.243
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SESSION TITLE: Critical Care in the ICU

SESSION TYPE: Original Investigation Poster Discussion

PRESENTED ON: Monday, October 24, 2016 at 12:00 PM - 01:30 PM

PURPOSE: While the primary injury from an acute ischemic stroke can be devastating, it is the secondary cerebral injury that is often fatal. This primarily occurs secondary to neurogenic brain edema from loss of the Na/K ATPase function on the cellular membrane resulting in swelling.1 . The mortality reported from malignant MCA strokes can range from 70-80% with medical management.2 In some cases elective hemicraniectomy can provide a survival benefit and decrease morbidity at one year compared to medical management.3,4,5,6,7 Osmotherapy represents an alternative and in some cases a temporizing medical therapy. 8 The aim of our study is to assess the effectiveness of a recent protocol derived for administration of hypertonic saline in our medical ICU for patients with large ischemic strokes

METHODS: A retrospective chart review of 27 patients admitted to intensive care at our institution during the 2015 calendar year that were administered hypertonic saline per protocol for ischemic or hemorrhagic stroke. The primary endpoint measured is % of patients that reach the target range for Na and osmolarity.. Secondary endpoints include in patient mortality, ICU length of stay, and hospital length of stay. The target serum sodium is 150-155 mEq/L and goal osmolarity is 300-360 mOsm/L. Na is measured every 4 hours and adjustments are made according to the protocol.

RESULTS: Our sample population is composed of 63% males with an average age of 63±9.7 years. The vast majority of strokes in the study were primary ischemic strokes (85%) and 15% of the ischemic strokes experienced a hemorrhagic conversion. Of the sample population, 19% received tPA prior and 3 patients had interventional neurology procedure done prior to placement on the hypertonic saline protocol. The NIH score at or near the time of initiation of the hypertonic saline protocol is 18±6.2. The ICU length of stay is 7.7±4.4 days. We achieved our Na goal in 70% of our patients. 59% of the patients had a serum osmolarity in target range. This resulted in an in- hospital mortality rate of 30% in our sample population.

CONCLUSIONS: Our preliminary analysis indicted that the hypertonic saline protocol was successful in reaching its sodium goal in a majority of patients. While the study is not powered to determine a true mortality benefit, the mortality rate in this population is superior to published data on severe strokes.

CLINICAL IMPLICATIONS: The population studied is generalizable to other populations of stroke patients that require intensive care. This preliminary data suggest that it is important to continue to study protocolized administration of hypertonic saline for osmotherpay in severe stroke.

DISCLOSURE: The following authors have nothing to disclose: Robert Stewart, Shekhar Ghamande, Heath White, Jennifer Rasmussen, Leigh Allen

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