Cite this post as:
Neha Dangayach. NeuroEMCrit – Everything you wanted to know about Hyperosmolar agents for the Management of ICP and Cerebral Edema. EMCrit Blog. Published on October 11, 2020. Accessed on January 19th 2022. Available at [https://emcrit.org/emcrit/hyperosmolar-agents-icp-emergencies/ ].
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Unless otherwise noted at the top of the post, the speaker(s) and related parties have no relevant financial disclosures.
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Thanks for doing this! I’m so excited for the new NeuroEMcrit, we need more of it! Maybe you can have your own podcasts too!
Thank you so much for your kind words! In 2021 I hope to become more consistent with my blog posts…there are lots of great trials to cover. Please also send me NCC topics you’d like me to cover. Once I become a pro at blogs I hope I can delve into podcasts 🙂
Hi. Excellent post.
I have a few queries.
1. In intra cranial bleed, like an intraparenchymal or pontine bleed – is there any role of osmolar therapy?
2. Will you prefer saline over mannitol in cases with intra parenchymal bleed – as there is a possibility of osmolar agents leaking out of BBB and worsening tissue edema.
3. Uptodate recommends use of 3 pc saline as continuous infusion and 21 pc as bolus, but no explanation given. Any comments?
Thank you so much Jacob. 1) Pontine hemorrhages usually tend to be primary hemorrhages due to hypertension; rarely they will secondary ICHs for eg. due to a pontine AVM. Depending upon whether there’s associated IVH and hydrocephalus or not, your patient could benefit from hyperosmolar treatments, EVD placement etc. 2) This concern thankfully hasn’t been been shown to affect patients or worsen cerebral edema or patient outcomes in patients with ICH https://www.ahajournals.org/doi/10.1161/STROKEAHA.115.009357 3) Based on the NCS guidelines for hyperosmolar therapies, bolus therapies (irrespective of the concentration you choose) may be preferable as compared to continuous drips.
one possible addition…what is written is for DEVELOPED systems… in Resource Limited Environs, (RLEs ), please consider NaHCO3-.
Great point Sean. https://pubmed.ncbi.nlm.nih.gov/27673506/ Although there isn’t a lot of data to support this, based on the current literature, it could be a potentially safe and effective alternative.
Thanks for the post. Can you explain the SIBICC recommendation of giving hyperosmolar therapy on an intermittent rather than scheduled basis? To me, this is akin to caring for a patient with a history of HTN who has an ICH and intermittently dosing antiHTN medication or only intermittently giving insulin to a patient with diabetes. When hyperosmolar therapy has been given intermittently a few or more times in a 12-18 hour period to a patient with severe TBI, who has significant edema on imaging, and it is day 2-4 (or 3-5) wouldn’t it be best to schedule this therapy and… Read more »
Can you talk about the speed of correcting the sodium to whatever “goal” you pick?
Thank you for the excellent post. A few questions: In your opinion, is there role for 8.4% sodium bicarbonate as a temporising measure for herniating TBI patients when HTS and mannitol are not available (e.g. preclinically)? Do you know of any supporting evidence (safety, efficacy) and are concerns regarding potential rises in CO2 justified? Thank you and looking forward to further posts!
Thank you so much Patrick. https://pubmed.ncbi.nlm.nih.gov/27673506/ While sodium bicarbonate is a potentially safe and effective alternative to mannitol or other forms of hypertonic saline; multiple doses of NaHCO3 as you correctly pointed out could lead to hypercarbia. We aim for permissive hypocarbia for patients with cerebral edema as a temporizing measure, so if you’re using NaHCO3 for ICP crises/cerebral edema treatment, my suggestion would be to keep a closer eye on your patient’s ETCO2 or PaCO2 and adjust the vent to compensated appropriately.
Thanks so much for this.
Thank you so much for reading Mariana. If there are any specific NCC topics you’d like me to cover please let me know.
It was a very informative article for me, although it was in general in medical language. To my surprise, it was clear to me and it was even fun to read. I am sure that before you publish it, you did a great job and tried to convey this to those who will read this article. My younger sister was born with ICP and for a long time we did not know what to do and how to help her. Sometimes it even seemed to me that our hopes and efforts were useless. But your article gave our family a… Read more »
Thank you for your comments. Hope your sister is doing well. I hope that she is under the care of a neurologist. The uses of hyperosmolar therapies that I covered in this post are meant for acute increases in ICP. Allergic reactions to mannitol have been reported but tend to be very rare.
Super excited to see you cover neurocritical care topics! Keep it coming please!
Thank you so much Marisa. Please let me know if there are any particular NCC topics you’d like me to cover.
[…] An opening pressure will be obtained on placement. Anything >20 mmHg (~27 cmH2O) should trigger management of intracranial hypertension […]