Treatment of refractory intracranial hypertension in severe traumatic brain injury with repetitive hypertonic/hyperoncotic infusions.

Rapid resuscitation of clinical and experimental traumatic brain injury (TBI) with hypertonic saline (HS) has been shown to improve neurological function and decrease intracranial pressure (ICP). The purpose of the present study was to test the efficacy of administration of HS (7.5%) combined with 6% hydroxyethyl starch (molecular weight 200,000/0.60-0.66; HHES) for the treatment of intracranial hypertension refractory to standard therapy in patients with severe TBI. With approval of the Institutional Ethics Committee six consecutive patients with severe TBI (GCS < 8) between 22 and 47 years of age (mean 32) who met the inclusion criteria (therapy resistant ICP > 25 mmHg, cerebral perfusion pressure (CPP) < 60 mmHg, plasma-Na+ < 150 mOsm and > 4 hours since the last HS/HHES treatment) were prospectively enrolled in the study. Patients received between one and ten bolus infusions of maximal 250 ml HS/HHES at a rate of 20 ml/min. A total of 32 infusions were given. ICP and CPP before treatment were 45 +/- 15 and 52 +/- 18 mmHg, respectively. Administration of HS/HHES significantly lowered ICP to 25 +/- 14 mmHg and improved CPP to 72 +/- 16 mmHg at 30 min without affecting arterial blood pressure or blood gases. Plasma sodium normalized within 30 min. HS/HES might become an interesting addition to conventional treatment maneuvers currently used for ICP therapy. It reduces otherwise therapy-resistant intracranial hypertension without negatively affecting blood pressure, blood gases and cerebral perfusion.