Which fluid for resuscitation in traumatic brain injury?

D. James Cooper

Hypertonic saline has many potential advantages suggesting benefit as a resuscitation fluid for patients with traumatic brain injury (TBI), but a randomised trial in Victorian pre-hospital TBI patients found that neurological outcomes were unchanged.

Albumin and saline are similarly effective for resuscitation of critically ill patients in general. However the safety of albumin resuscitation for patients with traumatic brain injury (TBI) was questioned after the 6997 patient Australian and New Zealand SAFE study. TBI patients had better 28 day survival when resuscitated using saline alone rather than albumin alone.

This unexpected observation has now been examined in more detail by the SAFE study investigators within the ANZICS-Clinical Trials Group. A follow-up study established baseline equivalence of key prognostic factors in these patients and also prospectively measured functional neurological outcomes 24 months after injury.

Saline resuscitation was associated with lower mortality than albumin at all the time points assessed, and functional neurological outcomes in the survivors were similar. The mechanism for the substantial difference in predominantly short term mortality is speculative and is under investigation in another study.

While numerous expensive new therapies have proved ineffective to improve outcomes in critically ill TBI patients, simply avoiding albumin resuscitation may substantially improve their survival. Hypertonic saline is best reserved for control of intracranial hypertension.