Hypertonic saline

[E tank]

Hey all,
Just throwing this out there purely for curiosity's sake...what are folk's experience with it? Under what conditions/circumstances is it used by HEMS or EMS? Is it initiated pre-hospital frequently or just continued IFT?

Kind of a mundane question...

 

[NomadicMedic]

Not at all in any EMS system I've worked in, nor have I heard of it being used in the field anywhere. Hard to justify without any labs, no?

 

[Operations Guy]

Hey all,
Just throwing this out there purely for curiosity's sake...what are folk's experience with it? Under what conditions/circumstances is it used by HEMS or EMS? Is it initiated pre-hospital frequently or just continued IFT?

Kind of a mundane question...

I've only seen it be used in the IFT setting after labs. Reason is serum sodium levels cannot be measured in the field. Most of the time it was used on TBI patients with high ICP.

 

[EpiEMS]

I've never seen it on any of the protocol or equipment lists I've read. I can't help but wonder if it is likely to be used without, say, an iStat? So maybe in a CCT setting, like @Operations Guy said.

 

[WolfmanHarris]

Last I saw it prehospital was during a research trial a few years back. They halted it early due to complications and negative outcomes.

 

[E tank]

I've never seen it on any of the protocol or equipment lists I've read. I can't help but wonder if it is likely to be used without, say, an iStat? So maybe in a CCT setting, like @Operations Guy said.

Well, a few years back it was all the rage for volume resus in trauma with some pretty impressive stuff coming out of the military experience. Interestingly, it's use in place of mannitol in neurotrauma/surgery kind of took off after the attention it got from its use in volume expansion.

 

[EpiEMS]

Last I saw it prehospital was during a research trial a few years back. They halted it early due to complications and negative outcomes.

Was it part of the ROC study?

 

[WolfmanHarris]

Was it part of the ROC study?

Ya I think so.

 

[Operations Guy]

I think 3% percent in the the ICU setting and 2% percent for IFT cause labs can be pushed out to 6 hours if Im not mistaken. Labs really need to be kept an eye on as overcorrection of serum sodium levels is common and have to be reversed with D5W or even oral water intake in extreme cases. Also last I heard it was given via central line and only peripheral IV while the patient is showing impending herniation.

 

[EpiEMS]

Well, a few years back it was all the rage for volume resus in trauma with some pretty impressive stuff coming out of the military experience. Interestingly, it's use in place of mannitol in neurotrauma/surgery kind of took off after the attention it got from its use in volume expansion.

Very interesting! I think this is related to the aforementioned ROC study...but it seems like the evidence isn't particularly favorable?

 

[VentMonkey]

The 3% our service carries is for predominantly IFT's, TMK. It isn't used a whole not, and in fact what we have now is on back order, but my partner managed to actually find some 3% to hold us over until the new year, which I don't see us using before then. The local hospitals seem to have a preference for Mannitol when we do pick up, and/ or transfer brain-injured patients. It's typically switched from their pumps to ours, and suffices for transport.

I was able to learn about how most of the more "cutting-edge" neuro ICU's seem to currently favor HTS over Mannitol through some of the CCP coursework I have done. @E tank if you have an article worth citing, I wouldn't mind taking a gander.

 

[VFlutter]

We have considered replacing our Mannitol with 3% saline for TBIs.

 

[Operations Guy]

The 3% our service carries is for predominantly IFT's, TMK. It isn't used a whole not, and in fact what we have now is on back order, but my partner managed to actually find some 3% to hold us over until the new year, which I don't see us using before then. The local hospitals seem to have a preference for Mannitol when we do pick up, and/ or transfer brain-injured patients. It's typically switched from their pumps to ours, and suffices for transport.

I was able to learn about how most of the more "cutting-edge" neuro ICU's seem to currently favor HTS over Mannitol through some of the CCP coursework I have done. @E tank if you have an article worth citing, I wouldn't mind taking a gander.[/QUOTE

Nevermind should of read the whole thing

 

[Operations Guy]

Well, a few years back it was all the rage for volume resus in trauma with some pretty impressive stuff coming out of the military experience. Interestingly, it's use in place of mannitol in neurotrauma/surgery kind of took off after the attention it got from its use in volume expansion.

Are you talking about Hextend? If so it's a different beast then 3%. I have seen Hextend used in military applications but never civilian setting.

 

[Operations Guy]

Here's an interesting read on Hextend from the army.

https://www.google.com/url?q=http:/...ggmMAs&usg=AFQjCNFm0HqbEDjemRTA7L5vbwgfQZnJZg

 

[E tank]

Are you talking about Hextend? If so it's a different beast then 3%. I have seen Hextend used in military applications but never civilian setting.

The hetastarches (Hextend and Hespan) got a pretty good ride about 10 years ago because they were seen as a clean (non blood product) quick volume expander that stayed intravascular (about 40% of the infused volume over 24 hr). I used them a lot but they were implicated with AKI in critical patients and bleeding with doses over 20 or so ml/kg. But some of that data was from animal models and I think the Europeans made a statement along those that more or less ended it's use. The FDA put out a warning and that was that. Too bad, to, because it was really useful.

 

[E tank]

Here's an interesting read on Hextend from the army.

https://www.google.com/url?q=http:/...ggmMAs&usg=AFQjCNFm0HqbEDjemRTA7L5vbwgfQZnJZg

Well, leave it to the military to for a reasoned opinion based on good data. Would that private practice and academic medicine follow suit. Hate to sound pat and trite, but the defensive medicine bogey man strikes again, IMHO.

 

[E tank]

We have considered replacing our Mannitol with 3% saline for TBIs.

You'd be in good company.

 

[VFlutter]

You'd be in good company.

Unfortunately I believe the decision is based more on shelf life than actual efficacy of treatment.

 

[E tank]

Unfortunately I believe the decision is based more on shelf life than actual efficacy of treatment.

Well, if they get it right, who cares why