Fluid and electrolyte management: Hyperosmolar euvolemia and the use of hypertonic saline for intracranial hypertension

The management of raised intracranial pressures (ICPs) involves a series of steps pursued in series or in parallel that can lower the ICP. Routine measures include positioning the head in a neutral position, controlling ventilation to prevent hypoxia and hypercapnia, maintaining an adequate bowel regimen to prevent increased intraabdominal pressure, and administering adequate sedation and analgesia, and preventing fever and hypertension may be enough to lower ICP below 20 mmHg in certain cases [1]. Persistent intracranial hypertension, however, may require other measures. These consist of medical therapies such as heavier sedation and/or paralysis, hyperventilation to maintain PaCO2 (partial pressure of arterial carbon dioxide) at 30–35 mmHg, hyperosmolar therapy, barbiturate coma, and hypothermia or procedural or surgical therapies such as cerebrospinal fluid (CSF) drainage and decompressive cranial surgery [1]. This chapter focuses on the use of hypertonic saline to lower the ICP in patients with traumatic brain injury (TBI).