Introduction: The urgent management of intracranial pressure (ICP) following a traumatic brain injury (TBI) is tantamount to improved morbidity and mortality outcomes for patients. Traditionally, hypertonic saline (HTS) has been widely used in patients with TBI, but is also associated with hyperchloremic-induced metabolic acidosis. Pharmacologically, this could be mitigated by utilizing hypertonic bicarbonate solutions. We present the clinical course of two patients who received intermittent courses of both 3% sodium solutions and hypertonic bicarbonate solutions.
Description: Case 1: A 60-year-old male with a past medical history of polysubstance abuse, chronic pain, and hypertension presented to the emergency department as a Level 1 trauma following an unwitnessed fall and suffered a severe TBI. He was initially started on 3% HTS to achieve a serum sodium of 145-155 mEq/L, but his serum chloride increased from 106 to 120 mEq/L within 48 hours. A hypertonic bicarbonate infusion of 0.5 mEq/L of sodium was initiated at 25-50 mL/hour to replace the HTS, which resulted in the patient maintaining their serum sodium within the targeted range but lowering the serum chloride to 98 with 24 hours of initiation.
Case 2: A 41-year-old male with a past medical history of hypertension presented to the emergency department as a Level 1 trauma following a motorcycle accident, in which he suffered a severe TBI. The patient was initiated on a 3% HTS infusion to achieve a serum sodium of 155 mEq/L, which simultaneously resulted in a serum chloride level of 109 mEq/L. A hypertonic bicarbonate infusion with 0.5 mEq/L of sodium was initiated at 25-50 mL/hour was administered instead of the HTS, which resulted in a serum sodium level of 148-154 mEq/L and a serum chloride level of 100 mEq/L.
Discussion: The clinical utility of hypertonic sodium bicarbonate solutions in TBI patients has not yet been firmly established in the literature, though advantages include the achievement of serum sodium goals while eliminating hyperchloremia. Ideal concentrations of sodium bicarbonate and diluent fluids remain an area of interest and warrant further clinical study and evaluation.
