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Critical Care Commentary: Hypertonic saline as osmolar therapy?
Hypertonic saline (HTS) at various concentrations is used as an osmolar agent to limit edema formation, thereby limiting its clinical consequences. Primarily used in disorders of the central nervous system, its use attempts to diminish tissue or intracellular water accumulation by raising intravascular osmolarity (sodium levels). Traditionally, this was solely used in the treatment of clinically symptomatic hyponatremia, in which the rise in extracellular sodium limits intracellular water accumulation, reversing CNS symptoms related to neuronal cell swelling.
The osmolar effects of HTS have also been utilized in trauma resuscitation, where given as bolus administration, it can rapidly expand intravascular volume by drawing from the extravascular compartments.
Physiology
The essential idea of osmolar therapy is that water will follow an osmolar concentration gradient if separated by an intact semipermeable membrane (Ropper et al. N Engl J Med. 2012: 367[8]:746). This works well in the treatment of certain disorders and less so in others. Indeed, it is clear that acute increases in tonicity have effects on alleviating tissue edema, most notably in the administration of mannitol. By lowering brain edema, mannitol lowers intracranial pressure, thus improving the neurologic findings (Bratton et al. J Neurotrauma. 2007;24 Suppl 1:S14-20). However, acute changes in osmolarity can also worsen conditions as seen when patients with renal failure and CNS injury undergo dialysis or in overly aggressive treatment of patients with hyponatremia. In such patients, slow gradual dialysis and implied gradual changes in volume and osmolarity are safer. Similarly, in patients with hyponatremia, a gradual rise in serum sodium is often prudent.
It is safe to say that as in most medical-clinical areas, there are few large controlled trials looking at HTS benefits. Specifically, the use of HTS has been examined in the following conditions: severe hyponatremia, elevated intracranial pressure, burn victims, and trauma resuscitation.
Hyponatremia
In syndrome of inappropriate antidiuretic hormone secretion (SIADH) or any symptomatic hyponatremic presentations, the goal is to quickly raise the sodium and hence the osmolarity of the extracellular space to achieve a gradient allowing intracellular water to equilibrate. The normalization of cellular volume and water prompts the normalization of neuron function and the patient’s symptoms.
In symptomatic patients there is an initial "bolus" over 10 minutes of HTS (3 mmol/kg body weight), followed by infusion. HTS at a low concentration (3%) is continuously infused to reach a precalculated sodium level that only approaches normal with frequent monitoring of serum sodium levels. The process works well providing that the (rise) return of the serum sodium is not too quick or overdone. Proper monitoring is essential since rapid correction can potentiate central pontine myelinolysis. Fluid restriction, change in medications, and/or treating the underlying cause are the other interventions.
Emergency resuscitation in trauma
The trauma literature has suggested that at high concentrations of HTS can be beneficial in the initial resuscitation of hypovolemic trauma patients (Patanwala et al. Am J Health-Syst Pharm. 2010;67[22]:1920). When used as a bolus, and not continuously, it may provide an initial boost in intravascular volume by drawing from extravascular "reserves," for example, from tissue and intracellular spaces. Bolus doses in the literature have ranged from 7.5% to 20%, 100 to 30 mL, respectively. This may buy valuable minutes while standard crystalloid resuscitation is provided.
However, the literature, as yet, has not supported any benefit over saline.
Though there are studies touting mortality benefits, a Cochrane review concluded that hypertonic crystalloids were no better than isotonic or near-isotonic crystalloids for fluid resuscitation in trauma patients (Bunn et al. Cochrane Database Syst Rev. 2004;3:CD002045). In fairness, many of the studies administered their HTS with dextran, and the latter has since been shown to have complications such as renal failure. In those studies showing benefit, HTS appeared to improve survival in those with Glasgow Coma Scale scores of <8 or MAP <70 mm Hg.
At this point, the evidence does not support HTS providing any additional benefit over isotonic crystalloid solutions in trauma.
Burns
Use of HTS in patients with burn injury has been shown to decrease the volume required for resuscitation. Unfortunately, in one prospective study, results indicated that HTS increased rates of renal failure (40% vs 10.1%, P less than .001) and mortality (53.8% vs 26.6%, P less than .001) as compared with those patients who did not receive HTS (Huang et al. Ann Surg. 1995;221[5]:543). At this stage, guidelines from the American Burn Association have suggested that HTS may be used for burn shock resuscitation by experienced providers with close monitoring to avoid excessive hypernatremia.
Intracranial pressure management (HTS infusion)
HTS uses for intracranial pressure (ICP) treatment include bolus therapy for acute and refractory ICP as in herniation and as prophylaxis (Himmelseher et al. Curr Opin Anaesthesiol. 2007;20[5]:414).
Rescue
In patients with dangerously elevated ICP and/or impending herniation, bolus HTS has been found to be equally as effective as mannitol in reducing ICP (Kamel et al. Crit Care Med. 2011;39[3]:554).
The data support bolus HTS regardless of the etiology, for example, trauma, ischemia, or tumor. These studies have used small boluses of HTS in concentrations as high as 30% to achieve these outcomes. Mannitol has traditionally been used but can cause hypotension through diuresis as well as acute kidney injury (AKI). Hypotension can lead to diminished cerebral perfusion pressure, a clear risk for poorer outcomes in traumatic brain injury (TBI). HTS may be ideal over mannitol in those patients with concomitant volume depletion.
Maintenance osmolar therapy
At a lower saline concentration (3%), HTS has been used as a continuous infusion to maintain relatively high serum sodium levels in patients with CNS disease (Froelich et al. Crit Care Med. 2009;37[4]:1433). This is somewhat preemptive with the presumption that higher plasma sodium concentrations would serve to minimize CNS edema through osmolar effects. In this setting, HTS therapy constitutes a preventative strategy in the hopes of limiting rises in ICP and not a treatment for acute increases in ICP. Other possible mechanisms that would explain positive HTS’s effects on reducing ICP include rheological, hemodynamic, and hormonal.
Though commonly used, there is no clear evidence that HTS significantly affects CNS edema. In TBI, the literature is composed primarily of case reports, case series, and small controlled groups. Many of these studies did not use a similar concentrations of HTS, while others included dextrans. The results were not uniform; some showed improvement as measured by the decreased need for intervention to lower ICP, primarily among children, while others showed no benefit. Only one of these studies suggested neurological benefits (Hauer et al. Crit Care Med. 2011;39[7]:1766). Some have identified various complications inclusive of deep venous thrombosis, AKI, increased infections, and potassium abnormalities (Coritsidis GN et al. Crit Care Med. 2009;37:2009:464a).
In patients with severe cerebrovascular disease, but not TBI, HTS was found to be safe. Reasons for the lack of benefits of this therapy would include a disrupted blood brain barrier and possible equilibration of osmoles across it.
Conclusion
The essential idea of osmolar therapy is that water will follow an osmolar concentration gradient if separated by an intact semipermeable membrane. To date, HTS has literature support in its use in clinically relevant hyponatremia and in the management of refractory ICP as rescue of acute elevations of ICP (herniation). Both are treatments in emergency situations. The former has been used for years and when properly monitored, is the treatment of choice. Interestingly enough, data are promising in the treatment of acute resuscitation for patients with hypotensive trauma, again an emergency condition.
The literature for empiric, continuously infused HTS, however, is lacking. In this setting and in burn victims, there are no clear indications for its use. Caution and, of course, more studies are needed.
Dr. Coritsidis is associate professor, chief division of nephrology, and director of the surgical/trauma ICU at Elmhurst Hospital Center, Elmhurst, N.Y.
Dr. Peter Spiro, FCCP commented:
This fine review by Dr. Coritsidis on osmolar therapy is not only timely but a needed perspective on the benefits and risks of HTS.
Most critical care physicians are early adopters of new therapies and historically osmolar therapies (mannitol,starches, etc.) have been difficult to manage optimally and can be potentially harmful. With the advent of HTS it was felt that this therapy could be widely used with limited complications or concern.As always, risk-benefit is key and with wider adoption and study, a more clear usage profile emerges. Though HTS has benefits, its wide adoption across the continuum of osmolar therapy is still being determined.
Dr. Spiro is the Section Editor of Critical Care Commentary.
This fine review by Dr. Coritsidis on osmolar therapy is not only timely but a needed perspective on the benefits and risks of HTS.
|
|
Most critical care physicians are early adopters of new therapies and historically osmolar therapies (mannitol, starches, etc.) have been difficult to manage optimally and can be potentially harmful. With the advent of HTS it was felt that this therapy could be widely used with limited complications or concern. As always, risk-benefit is key and with wider adoption and study, a more clear usage profile emerges. Though HTS has benefits, its wide adoption across the continuum of osmolar therapy is still being determined.
Dr. Peter Spiro, FCCP
Section Editor, Critical Care Commentary
This fine review by Dr. Coritsidis on osmolar therapy is not only timely but a needed perspective on the benefits and risks of HTS.
|
|
|
Most critical care physicians are early adopters of new therapies and historically osmolar therapies (mannitol, starches, etc.) have been difficult to manage optimally and can be potentially harmful. With the advent of HTS it was felt that this therapy could be widely used with limited complications or concern. As always, risk-benefit is key and with wider adoption and study, a more clear usage profile emerges. Though HTS has benefits, its wide adoption across the continuum of osmolar therapy is still being determined.
Dr. Peter Spiro, FCCP
Section Editor, Critical Care Commentary
This fine review by Dr. Coritsidis on osmolar therapy is not only timely but a needed perspective on the benefits and risks of HTS.
|
|
|
Most critical care physicians are early adopters of new therapies and historically osmolar therapies (mannitol, starches, etc.) have been difficult to manage optimally and can be potentially harmful. With the advent of HTS it was felt that this therapy could be widely used with limited complications or concern. As always, risk-benefit is key and with wider adoption and study, a more clear usage profile emerges. Though HTS has benefits, its wide adoption across the continuum of osmolar therapy is still being determined.
Dr. Peter Spiro, FCCP
Section Editor, Critical Care Commentary
Hypertonic saline (HTS) at various concentrations is used as an osmolar agent to limit edema formation, thereby limiting its clinical consequences. Primarily used in disorders of the central nervous system, its use attempts to diminish tissue or intracellular water accumulation by raising intravascular osmolarity (sodium levels). Traditionally, this was solely used in the treatment of clinically symptomatic hyponatremia, in which the rise in extracellular sodium limits intracellular water accumulation, reversing CNS symptoms related to neuronal cell swelling.
The osmolar effects of HTS have also been utilized in trauma resuscitation, where given as bolus administration, it can rapidly expand intravascular volume by drawing from the extravascular compartments.
Physiology
The essential idea of osmolar therapy is that water will follow an osmolar concentration gradient if separated by an intact semipermeable membrane (Ropper et al. N Engl J Med. 2012: 367[8]:746). This works well in the treatment of certain disorders and less so in others. Indeed, it is clear that acute increases in tonicity have effects on alleviating tissue edema, most notably in the administration of mannitol. By lowering brain edema, mannitol lowers intracranial pressure, thus improving the neurologic findings (Bratton et al. J Neurotrauma. 2007;24 Suppl 1:S14-20). However, acute changes in osmolarity can also worsen conditions as seen when patients with renal failure and CNS injury undergo dialysis or in overly aggressive treatment of patients with hyponatremia. In such patients, slow gradual dialysis and implied gradual changes in volume and osmolarity are safer. Similarly, in patients with hyponatremia, a gradual rise in serum sodium is often prudent.
It is safe to say that as in most medical-clinical areas, there are few large controlled trials looking at HTS benefits. Specifically, the use of HTS has been examined in the following conditions: severe hyponatremia, elevated intracranial pressure, burn victims, and trauma resuscitation.
Hyponatremia
In syndrome of inappropriate antidiuretic hormone secretion (SIADH) or any symptomatic hyponatremic presentations, the goal is to quickly raise the sodium and hence the osmolarity of the extracellular space to achieve a gradient allowing intracellular water to equilibrate. The normalization of cellular volume and water prompts the normalization of neuron function and the patient’s symptoms.
In symptomatic patients there is an initial "bolus" over 10 minutes of HTS (3 mmol/kg body weight), followed by infusion. HTS at a low concentration (3%) is continuously infused to reach a precalculated sodium level that only approaches normal with frequent monitoring of serum sodium levels. The process works well providing that the (rise) return of the serum sodium is not too quick or overdone. Proper monitoring is essential since rapid correction can potentiate central pontine myelinolysis. Fluid restriction, change in medications, and/or treating the underlying cause are the other interventions.
Emergency resuscitation in trauma
The trauma literature has suggested that at high concentrations of HTS can be beneficial in the initial resuscitation of hypovolemic trauma patients (Patanwala et al. Am J Health-Syst Pharm. 2010;67[22]:1920). When used as a bolus, and not continuously, it may provide an initial boost in intravascular volume by drawing from extravascular "reserves," for example, from tissue and intracellular spaces. Bolus doses in the literature have ranged from 7.5% to 20%, 100 to 30 mL, respectively. This may buy valuable minutes while standard crystalloid resuscitation is provided.
However, the literature, as yet, has not supported any benefit over saline.
Though there are studies touting mortality benefits, a Cochrane review concluded that hypertonic crystalloids were no better than isotonic or near-isotonic crystalloids for fluid resuscitation in trauma patients (Bunn et al. Cochrane Database Syst Rev. 2004;3:CD002045). In fairness, many of the studies administered their HTS with dextran, and the latter has since been shown to have complications such as renal failure. In those studies showing benefit, HTS appeared to improve survival in those with Glasgow Coma Scale scores of <8 or MAP <70 mm Hg.
At this point, the evidence does not support HTS providing any additional benefit over isotonic crystalloid solutions in trauma.
Burns
Use of HTS in patients with burn injury has been shown to decrease the volume required for resuscitation. Unfortunately, in one prospective study, results indicated that HTS increased rates of renal failure (40% vs 10.1%, P less than .001) and mortality (53.8% vs 26.6%, P less than .001) as compared with those patients who did not receive HTS (Huang et al. Ann Surg. 1995;221[5]:543). At this stage, guidelines from the American Burn Association have suggested that HTS may be used for burn shock resuscitation by experienced providers with close monitoring to avoid excessive hypernatremia.
Intracranial pressure management (HTS infusion)
HTS uses for intracranial pressure (ICP) treatment include bolus therapy for acute and refractory ICP as in herniation and as prophylaxis (Himmelseher et al. Curr Opin Anaesthesiol. 2007;20[5]:414).
Rescue
In patients with dangerously elevated ICP and/or impending herniation, bolus HTS has been found to be equally as effective as mannitol in reducing ICP (Kamel et al. Crit Care Med. 2011;39[3]:554).
The data support bolus HTS regardless of the etiology, for example, trauma, ischemia, or tumor. These studies have used small boluses of HTS in concentrations as high as 30% to achieve these outcomes. Mannitol has traditionally been used but can cause hypotension through diuresis as well as acute kidney injury (AKI). Hypotension can lead to diminished cerebral perfusion pressure, a clear risk for poorer outcomes in traumatic brain injury (TBI). HTS may be ideal over mannitol in those patients with concomitant volume depletion.
Maintenance osmolar therapy
At a lower saline concentration (3%), HTS has been used as a continuous infusion to maintain relatively high serum sodium levels in patients with CNS disease (Froelich et al. Crit Care Med. 2009;37[4]:1433). This is somewhat preemptive with the presumption that higher plasma sodium concentrations would serve to minimize CNS edema through osmolar effects. In this setting, HTS therapy constitutes a preventative strategy in the hopes of limiting rises in ICP and not a treatment for acute increases in ICP. Other possible mechanisms that would explain positive HTS’s effects on reducing ICP include rheological, hemodynamic, and hormonal.
Though commonly used, there is no clear evidence that HTS significantly affects CNS edema. In TBI, the literature is composed primarily of case reports, case series, and small controlled groups. Many of these studies did not use a similar concentrations of HTS, while others included dextrans. The results were not uniform; some showed improvement as measured by the decreased need for intervention to lower ICP, primarily among children, while others showed no benefit. Only one of these studies suggested neurological benefits (Hauer et al. Crit Care Med. 2011;39[7]:1766). Some have identified various complications inclusive of deep venous thrombosis, AKI, increased infections, and potassium abnormalities (Coritsidis GN et al. Crit Care Med. 2009;37:2009:464a).
In patients with severe cerebrovascular disease, but not TBI, HTS was found to be safe. Reasons for the lack of benefits of this therapy would include a disrupted blood brain barrier and possible equilibration of osmoles across it.
Conclusion
The essential idea of osmolar therapy is that water will follow an osmolar concentration gradient if separated by an intact semipermeable membrane. To date, HTS has literature support in its use in clinically relevant hyponatremia and in the management of refractory ICP as rescue of acute elevations of ICP (herniation). Both are treatments in emergency situations. The former has been used for years and when properly monitored, is the treatment of choice. Interestingly enough, data are promising in the treatment of acute resuscitation for patients with hypotensive trauma, again an emergency condition.
The literature for empiric, continuously infused HTS, however, is lacking. In this setting and in burn victims, there are no clear indications for its use. Caution and, of course, more studies are needed.
Dr. Coritsidis is associate professor, chief division of nephrology, and director of the surgical/trauma ICU at Elmhurst Hospital Center, Elmhurst, N.Y.
Dr. Peter Spiro, FCCP commented:
This fine review by Dr. Coritsidis on osmolar therapy is not only timely but a needed perspective on the benefits and risks of HTS.
Most critical care physicians are early adopters of new therapies and historically osmolar therapies (mannitol,starches, etc.) have been difficult to manage optimally and can be potentially harmful. With the advent of HTS it was felt that this therapy could be widely used with limited complications or concern.As always, risk-benefit is key and with wider adoption and study, a more clear usage profile emerges. Though HTS has benefits, its wide adoption across the continuum of osmolar therapy is still being determined.
Dr. Spiro is the Section Editor of Critical Care Commentary.
Hypertonic saline (HTS) at various concentrations is used as an osmolar agent to limit edema formation, thereby limiting its clinical consequences. Primarily used in disorders of the central nervous system, its use attempts to diminish tissue or intracellular water accumulation by raising intravascular osmolarity (sodium levels). Traditionally, this was solely used in the treatment of clinically symptomatic hyponatremia, in which the rise in extracellular sodium limits intracellular water accumulation, reversing CNS symptoms related to neuronal cell swelling.
The osmolar effects of HTS have also been utilized in trauma resuscitation, where given as bolus administration, it can rapidly expand intravascular volume by drawing from the extravascular compartments.
Physiology
The essential idea of osmolar therapy is that water will follow an osmolar concentration gradient if separated by an intact semipermeable membrane (Ropper et al. N Engl J Med. 2012: 367[8]:746). This works well in the treatment of certain disorders and less so in others. Indeed, it is clear that acute increases in tonicity have effects on alleviating tissue edema, most notably in the administration of mannitol. By lowering brain edema, mannitol lowers intracranial pressure, thus improving the neurologic findings (Bratton et al. J Neurotrauma. 2007;24 Suppl 1:S14-20). However, acute changes in osmolarity can also worsen conditions as seen when patients with renal failure and CNS injury undergo dialysis or in overly aggressive treatment of patients with hyponatremia. In such patients, slow gradual dialysis and implied gradual changes in volume and osmolarity are safer. Similarly, in patients with hyponatremia, a gradual rise in serum sodium is often prudent.
It is safe to say that as in most medical-clinical areas, there are few large controlled trials looking at HTS benefits. Specifically, the use of HTS has been examined in the following conditions: severe hyponatremia, elevated intracranial pressure, burn victims, and trauma resuscitation.
Hyponatremia
In syndrome of inappropriate antidiuretic hormone secretion (SIADH) or any symptomatic hyponatremic presentations, the goal is to quickly raise the sodium and hence the osmolarity of the extracellular space to achieve a gradient allowing intracellular water to equilibrate. The normalization of cellular volume and water prompts the normalization of neuron function and the patient’s symptoms.
In symptomatic patients there is an initial "bolus" over 10 minutes of HTS (3 mmol/kg body weight), followed by infusion. HTS at a low concentration (3%) is continuously infused to reach a precalculated sodium level that only approaches normal with frequent monitoring of serum sodium levels. The process works well providing that the (rise) return of the serum sodium is not too quick or overdone. Proper monitoring is essential since rapid correction can potentiate central pontine myelinolysis. Fluid restriction, change in medications, and/or treating the underlying cause are the other interventions.
Emergency resuscitation in trauma
The trauma literature has suggested that at high concentrations of HTS can be beneficial in the initial resuscitation of hypovolemic trauma patients (Patanwala et al. Am J Health-Syst Pharm. 2010;67[22]:1920). When used as a bolus, and not continuously, it may provide an initial boost in intravascular volume by drawing from extravascular "reserves," for example, from tissue and intracellular spaces. Bolus doses in the literature have ranged from 7.5% to 20%, 100 to 30 mL, respectively. This may buy valuable minutes while standard crystalloid resuscitation is provided.
However, the literature, as yet, has not supported any benefit over saline.
Though there are studies touting mortality benefits, a Cochrane review concluded that hypertonic crystalloids were no better than isotonic or near-isotonic crystalloids for fluid resuscitation in trauma patients (Bunn et al. Cochrane Database Syst Rev. 2004;3:CD002045). In fairness, many of the studies administered their HTS with dextran, and the latter has since been shown to have complications such as renal failure. In those studies showing benefit, HTS appeared to improve survival in those with Glasgow Coma Scale scores of <8 or MAP <70 mm Hg.
At this point, the evidence does not support HTS providing any additional benefit over isotonic crystalloid solutions in trauma.
Burns
Use of HTS in patients with burn injury has been shown to decrease the volume required for resuscitation. Unfortunately, in one prospective study, results indicated that HTS increased rates of renal failure (40% vs 10.1%, P less than .001) and mortality (53.8% vs 26.6%, P less than .001) as compared with those patients who did not receive HTS (Huang et al. Ann Surg. 1995;221[5]:543). At this stage, guidelines from the American Burn Association have suggested that HTS may be used for burn shock resuscitation by experienced providers with close monitoring to avoid excessive hypernatremia.
Intracranial pressure management (HTS infusion)
HTS uses for intracranial pressure (ICP) treatment include bolus therapy for acute and refractory ICP as in herniation and as prophylaxis (Himmelseher et al. Curr Opin Anaesthesiol. 2007;20[5]:414).
Rescue
In patients with dangerously elevated ICP and/or impending herniation, bolus HTS has been found to be equally as effective as mannitol in reducing ICP (Kamel et al. Crit Care Med. 2011;39[3]:554).
The data support bolus HTS regardless of the etiology, for example, trauma, ischemia, or tumor. These studies have used small boluses of HTS in concentrations as high as 30% to achieve these outcomes. Mannitol has traditionally been used but can cause hypotension through diuresis as well as acute kidney injury (AKI). Hypotension can lead to diminished cerebral perfusion pressure, a clear risk for poorer outcomes in traumatic brain injury (TBI). HTS may be ideal over mannitol in those patients with concomitant volume depletion.
Maintenance osmolar therapy
At a lower saline concentration (3%), HTS has been used as a continuous infusion to maintain relatively high serum sodium levels in patients with CNS disease (Froelich et al. Crit Care Med. 2009;37[4]:1433). This is somewhat preemptive with the presumption that higher plasma sodium concentrations would serve to minimize CNS edema through osmolar effects. In this setting, HTS therapy constitutes a preventative strategy in the hopes of limiting rises in ICP and not a treatment for acute increases in ICP. Other possible mechanisms that would explain positive HTS’s effects on reducing ICP include rheological, hemodynamic, and hormonal.
Though commonly used, there is no clear evidence that HTS significantly affects CNS edema. In TBI, the literature is composed primarily of case reports, case series, and small controlled groups. Many of these studies did not use a similar concentrations of HTS, while others included dextrans. The results were not uniform; some showed improvement as measured by the decreased need for intervention to lower ICP, primarily among children, while others showed no benefit. Only one of these studies suggested neurological benefits (Hauer et al. Crit Care Med. 2011;39[7]:1766). Some have identified various complications inclusive of deep venous thrombosis, AKI, increased infections, and potassium abnormalities (Coritsidis GN et al. Crit Care Med. 2009;37:2009:464a).
In patients with severe cerebrovascular disease, but not TBI, HTS was found to be safe. Reasons for the lack of benefits of this therapy would include a disrupted blood brain barrier and possible equilibration of osmoles across it.
Conclusion
The essential idea of osmolar therapy is that water will follow an osmolar concentration gradient if separated by an intact semipermeable membrane. To date, HTS has literature support in its use in clinically relevant hyponatremia and in the management of refractory ICP as rescue of acute elevations of ICP (herniation). Both are treatments in emergency situations. The former has been used for years and when properly monitored, is the treatment of choice. Interestingly enough, data are promising in the treatment of acute resuscitation for patients with hypotensive trauma, again an emergency condition.
The literature for empiric, continuously infused HTS, however, is lacking. In this setting and in burn victims, there are no clear indications for its use. Caution and, of course, more studies are needed.
Dr. Coritsidis is associate professor, chief division of nephrology, and director of the surgical/trauma ICU at Elmhurst Hospital Center, Elmhurst, N.Y.
Dr. Peter Spiro, FCCP commented:
This fine review by Dr. Coritsidis on osmolar therapy is not only timely but a needed perspective on the benefits and risks of HTS.
Most critical care physicians are early adopters of new therapies and historically osmolar therapies (mannitol,starches, etc.) have been difficult to manage optimally and can be potentially harmful. With the advent of HTS it was felt that this therapy could be widely used with limited complications or concern.As always, risk-benefit is key and with wider adoption and study, a more clear usage profile emerges. Though HTS has benefits, its wide adoption across the continuum of osmolar therapy is still being determined.
Dr. Spiro is the Section Editor of Critical Care Commentary.
