Siti Chasnak Saleh

Dept. Anesthesiology & Reanimation

Surabaya
 Isolated head trauma does
NOT cause shock
(possible in pediatrics)
 TBI +
hypotension
(2X)
2nd brain injury
ICP
Hypoxia IV fluid
Hypotension

Mortality rate Crystalloids, (NS,HTS),

31%-49% Colloids (HES) ?

80000~90000
long term morbidity

Severe traumatic brain injury (TBI)

CEREBRAL CIRCULATION RESPONSES
TO ACUTE HEAD INJURY

Decrease CBF
Impaire autoregulation
Increase ICP

To control ICP, maintain

CPP and then CBF
 Goals for volume therapy in
TBI

To prevent secondary brain injury

Treatment of increased ICP
To improve microcirculation
 Fluids resuscitation

COLLOIDS ?
CRYSTALLOIDS
 TBI and different types of
edema

Vasogenic edema (BBB breakdown)

Cytotoxic edema (secondary to ischemic insult
Cellular edema (resulting from neurotoxic insult)
 CEREBRAL EDEMA-
CYTOTOXIC

Intracellular process-
pump failure
Head trauma, post
ischemia, toxins,
hypoosmolality
Not steroid responsive
 Sodium contents and osmolality of fluids
administered to patients after neurotrauma

Fluids Na+ Osmolality

(mmol/L) (mOsm/l)

Lactated ringers 130 273

0.9% saline 145 308
Hypertonic Saline:
1.7% NaCl 291 582
3% NaCl 513 1026
7.5% NaCl 1283 2566
Colloid:
6% HES 154 310
HS-HES 1232 2264
plasma 295
5% albumin 310
20% mannitol -- 1098
 Osmolalities of solutions that have been used for
treatment of cerebral edema and intracranial
hypertension
Solution Na+ content (mmol/L) Osmolality (mosm/L)

0.9% saline 154 308

Lactated Ringer 130 275
20% mannitol ? 1245
25% mannitol ? 1375
3% saline 513 1026
7.5% saline 1283 2565
23.4% saline 4004 8008
7.5% saline/6%HES 1283 2570
 The osmotic properties of
intravenous fluids are
importatnt in determining their
efficacy and savety for use in
the present of brain injury
FLUID RESUSCITATION

Prompt restoration of systolic and MAP, and

then maintain CPP.
Hypotonic solution (LR) increases brain water
content than 0,9 % NS
Colloid maintained lower brain water than
crystalloid, and then decrease ICP. (Drummond
et al).
 HYPERTONIC SALINE

Rapid fluid shift from inside the cells to the

blood vessels
 Advantages of HTS for TBI
patients

Improved hemodynamics: plasma volume

expansion
Decreased cerebral edema: reduced ICP
Vasoregulation: reduced vasospasm
Immunomodulation
Neurochemical effects
 HTS (20%)

Noncontused
Contused area
area

- Decreased weight - Increased weight

- Increased SG without any
concomitant in
density.

Lescot et al, 2006

Change in weight of contusion according to the initial
volume assessed in percentage of the hemispheres

Lescot et al, 2006

Battistella & Wesner, 1991
Battistella & Wesner, 1991
Battistella & Wesner, 1991
Potential adverse effects of HTS

Excessive intravascular volume

Rebound increases of ICP
Electrolytes abnormality
Influence of HES infusion on
CBF in patients with TBI

Best results in patients with:

cerebral vasospasm
cerebral hypoperfusion
 HTS-HES
Sodium chloride is
responsible for the
osmotic gradient

Complex
mechanisms

HES is added to
maintain the short-
lived volume effect
of HTS
Crookes et al, J Trauma, 2004
Crookes et al, J Trauma, 2004
Crookes et al, J Trauma, 2004
Schwarz et al, Stroke 1998
Conclusion
Crystalloids are the best choice for general resuscitation
of trauma patients and traumatic brain injury. (SAFE
trials).
Albumin is contraindicated in the resuscitation of those
with brain injury (SAFE trials).
Hypertonic saline is safe alternative for the treatment of
elevated ICP in severe head injury.
Colloids should be used with caution in patients with
traumatic brain injury.
Colloids may have a secondary role in patients
unresponsive to crystalloids.
Infusion of HES influences CBF on patients with TBI
(especially cerebral vasospasm and cerebral
hypoperfusion)