Enteral free water in high ICP

Q: Patients with elevated Intra-Cranial Pressure (ICP) should not be fed enteral free water.

 A) True

B) False

 Answer: A 

Patients with elevated ICP should be kept euvolemic, rather normo- to hyperosmolar. Any hypotonic fluid administration, including enteral free water, should be avoided whenever possible. Isotonic fluids are usually utilized guided by close monitoring of labs. Serum osmolality is targeted to stay above 280 mOsm/L, between 295 and 305 mOsm/L. Colloids have no specific advantage. 

 Clinicians should be aware that hyponatremia is common in patients with elevated ICP, particularly in patients with subarachnoid hemorrhage SAH). Hypertonic saline in bolus, popularly known as 'salt bomb' can be used per clinical judgement.

 #neurology 

 References: 

 1. Schmoker JD, Shackford SR, Wald SL, Pietropaoli JA. An analysis of the relationship between fluid and sodium administration and intracranial pressure after head injury. J Trauma 1992; 33:476. 

 2. Tranmer BI, Iacobacci RI, Kindt GW. Effects of crystalloid and colloid infusions on intracranial pressure and computerized electroencephalographic data in dogs with vasogenic brain edema. Neurosurgery 1989; 25:173.

 3. SAFE Study Investigators, Australian and New Zealand Intensive Care Society Clinical Trials Group, Australian Red Cross Blood Service, et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med 2007; 357:874.