Hypertonic Solution as Treatment for ICP Crisis in ESRD


Transtentorial herniation:  acute unresponsiveness, decline in GCS >=2 pts with uni- or bilateral pupillary dilatation and loss of reactivity to light, and increase in ICP >20mmHg in acomatose patient x 5 mints +/- change in pupillary sie and reactivity.


  • 23.4% saline (30-60 mL bolus) over 5-10 minutes

– well-tolerated in renal failure, no observed pulmonary edema or overload despite high incidence of cardiovascular dysfunction in this population (small study)


Proposed Mechanism of Action: hypertonic saline causes osmolar gradient –> to fluid shifts, reduces brain mass, without significant diuresis

  • osmotic diuresis
  • vasoconstriction resulting in decreased cerebral volume
  • reduced blood viscosity
  • improved cerebral perfusion from volume expansion


Potential complications:

  1. hypotension – most common adverse event
  2. pulmonary edema
  3. arrhythmias
  4. coagulopathy
  5. hemolysis
  6. rebound ICP elevation

*mechanism for hypotension: ?not clarified yet, small animal study suggests may be mediated by sympathetic neural reflex and not a diuretic effect; others suggest may be due to vasodilatory effect; or maybe due to resolution of Cushing response



Hirsch, Karen G. et al. “Treatment Of Elevated Intracranial Pressure With Hyperosmolar Therapy In Patients With Renal Failure”. Neurocritical Care 17.3 (2012): 388-394.


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