Implementation of a standardized electronic medical record-integrated alternating hyperosmolar therapy protocol in neurocritical care: a single-center retrospective feasibility study.

BACKGROUND

Hyperosmolar therapy is a cornerstone of the medical management of cerebral edema and suspected intracranial hypertension. Despite widespread use of hypertonic saline and mannitol, substantial variability exists in agent selection, dosing, laboratory monitoring, treatment duration, and discontinuation practices. Standardized institutional protocols may improve consistency of care; however, reports describing their implementation in routine neurocritical care remain limited.

OBJECTIVE

To evaluate implementation of a standardized electronic medical record (EMR)-integrated alternating hyperosmolar therapy protocol in a neurocritical care unit and to describe protocol exposure, reasons for protocol discontinuation, and preliminary safety observations.

METHODS

We conducted a retrospective single-center observational study of consecutive adult patients managed using a standardized alternating hyperosmolar therapy protocol between January 2024 and January 2026. The protocol consisted of alternating 3% hypertonic saline and 20% mannitol every 12 h according to a predefined four-day de-escalating schedule integrated into the institutional EMR. Implementation was assessed descriptively using treatment exposure, protocol completion, and primary reasons for protocol discontinuation; no prespecified feasibility threshold was used. Secondary outcomes included adverse events and in-hospital mortality.

RESULTS

Seventeen patients were included. Six (35.3%) completed the four-day protocol, and 16 (94.1%) received at least two days of therapy. Protocol discontinuation most commonly reflected progression of the underlying neurological disease or changes in overall goals of care rather than treatment-related toxicity. Hypernatremia occurred in three patients (17.6%) and resulted in protocol discontinuation in one. Elevated serum osmolality occurred in one patient (5.9%). No new-onset protocol-related acute kidney injury, pulmonary edema, or decompensated heart failure occurred during protocol administration. Rebound cerebral edema could not be systematically assessed because invasive intracranial pressure monitoring and protocolized follow-up neuroimaging were not routinely performed. Overall in-hospital mortality was 52.9%.

CONCLUSION

Implementation of a standardized EMR-integrated alternating hyperosmolar therapy protocol was achievable in this retrospective single-center cohort. Most protocol discontinuations reflected progression of the underlying neurological disease or changes in overall goals of care rather than treatment-related toxicity. Although adverse events were infrequent, the retrospective design, absence of a comparator group, and small sample size preclude definitive conclusions regarding safety or efficacy. These findings support the feasibility of implementation and future prospective multicenter evaluation.