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Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury.
J Neurosurg 2015; 122(1):202-10JN

Abstract

OBJECT

Increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI) is associated with a higher mortality rate and poor outcome. Mannitol and hypertonic saline (HTS) have both been used to treat high ICP, but it is unclear which one is more effective. Here, the authors compare the effect of mannitol versus HTS on lowering the cumulative and daily ICP burdens after severe TBI.

METHODS

The Brain Trauma Foundation TBI-trac New York State database was used for this retrospective study. Patients with severe TBI and intracranial hypertension who received only 1 type of hyperosmotic agent, mannitol or HTS, were included. Patients in the 2 groups were individually matched for Glasgow Coma Scale score (GCS), pupillary reactivity, craniotomy, occurrence of hypotension on Day 1, and the day of ICP monitor insertion. Patients with missing or erroneous data were excluded. Cumulative and daily ICP burdens were used as primary outcome measures. The cumulative ICP burden was defined as the total number of days with an ICP of > 25 mm Hg, expressed as a percentage of the total number of days of ICP monitoring. The daily ICP burden was calculated as the mean daily duration of an ICP of > 25 mm Hg, expressed as the number of hours per day. The numbers of intensive care unit (ICU) days, numbers of days with ICP monitoring, and 2-week mortality rates were also compared between the groups. A 2-sample t-test or chi-square test was used to compare independent samples. The Wilcoxon signed-rank or Cochran-Mantel-Haenszel test was used for comparing matched samples.

RESULTS

A total of 35 patients who received only HTS and 477 who received only mannitol after severe TBI were identified. Eight patients in the HTS group were excluded because of erroneous or missing data, and 2 other patients did not have matches in the mannitol group. The remaining 25 patients were matched 1:1. Twenty-four patients received 3% HTS, and 1 received 23.4% HTS as bolus therapy. All 25 patients in the mannitol group received 20% mannitol. The mean cumulative ICP burden (15.52% [HTS] vs 36.5% [mannitol]; p = 0.003) and the mean (± SD) daily ICP burden (0.3 ± 0.6 hours/day [HTS] vs 1.3 ± 1.3 hours/day [mannitol]; p = 0.001) were significantly lower in the HTS group. The mean (± SD) number of ICU days was significantly lower in the HTS group than in the mannitol group (8.5 ± 2.1 vs 9.8 ± 0.6, respectively; p = 0.004), whereas there was no difference in the numbers of days of ICP monitoring (p = 0.09). There were no significant differences between the cumulative median doses of HTS and mannitol (p = 0.19). The 2-week mortality rate was lower in the HTS group, but the difference was not statistically significant (p = 0.56).

CONCLUSIONS

HTS given as bolus therapy was more effective than mannitol in lowering the cumulative and daily ICP burdens after severe TBI. Patients in the HTS group had significantly lower number of ICU days. The 2-week mortality rates were not statistically different between the 2 groups.

Authors+Show Affiliations

Departments of 1 Neurology and.

Pub Type(s)

Journal Article
Randomized Controlled Trial
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

25380107

Citation

Mangat, Halinder S., et al. "Hypertonic Saline Reduces Cumulative and Daily Intracranial Pressure Burdens After Severe Traumatic Brain Injury." Journal of Neurosurgery, vol. 122, no. 1, 2015, pp. 202-10.
Mangat HS, Chiu YL, Gerber LM, et al. Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury. J Neurosurg. 2015;122(1):202-10.
Mangat, H. S., Chiu, Y. L., Gerber, L. M., Alimi, M., Ghajar, J., & Härtl, R. (2015). Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury. Journal of Neurosurgery, 122(1), pp. 202-10. doi:10.3171/2014.10.JNS132545.
Mangat HS, et al. Hypertonic Saline Reduces Cumulative and Daily Intracranial Pressure Burdens After Severe Traumatic Brain Injury. J Neurosurg. 2015;122(1):202-10. PubMed PMID: 25380107.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury. AU - Mangat,Halinder S, AU - Chiu,Ya-Lin, AU - Gerber,Linda M, AU - Alimi,Marjan, AU - Ghajar,Jamshid, AU - Härtl,Roger, PY - 2014/11/8/entrez PY - 2014/11/8/pubmed PY - 2015/3/7/medline KW - AUC = area under the curve KW - BTF = Brain Trauma Foundation KW - CBF = cerebral blood flow KW - CMH = Cochran-Mantel-Haenszel KW - CPP = cerebral perfusion pressure KW - GCS = Glasgow Coma Scale KW - HTS = hypertonic saline KW - ICP = intracranial pressure KW - ICP burden KW - ICU = intensive care unit KW - RCT = randomized controlled trial KW - TBI = traumatic brain injury KW - hypertonic saline KW - intracranial pressure KW - mannitol KW - traumatic brain injury SP - 202 EP - 10 JF - Journal of neurosurgery JO - J. Neurosurg. VL - 122 IS - 1 N2 - OBJECT: Increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI) is associated with a higher mortality rate and poor outcome. Mannitol and hypertonic saline (HTS) have both been used to treat high ICP, but it is unclear which one is more effective. Here, the authors compare the effect of mannitol versus HTS on lowering the cumulative and daily ICP burdens after severe TBI. METHODS: The Brain Trauma Foundation TBI-trac New York State database was used for this retrospective study. Patients with severe TBI and intracranial hypertension who received only 1 type of hyperosmotic agent, mannitol or HTS, were included. Patients in the 2 groups were individually matched for Glasgow Coma Scale score (GCS), pupillary reactivity, craniotomy, occurrence of hypotension on Day 1, and the day of ICP monitor insertion. Patients with missing or erroneous data were excluded. Cumulative and daily ICP burdens were used as primary outcome measures. The cumulative ICP burden was defined as the total number of days with an ICP of > 25 mm Hg, expressed as a percentage of the total number of days of ICP monitoring. The daily ICP burden was calculated as the mean daily duration of an ICP of > 25 mm Hg, expressed as the number of hours per day. The numbers of intensive care unit (ICU) days, numbers of days with ICP monitoring, and 2-week mortality rates were also compared between the groups. A 2-sample t-test or chi-square test was used to compare independent samples. The Wilcoxon signed-rank or Cochran-Mantel-Haenszel test was used for comparing matched samples. RESULTS: A total of 35 patients who received only HTS and 477 who received only mannitol after severe TBI were identified. Eight patients in the HTS group were excluded because of erroneous or missing data, and 2 other patients did not have matches in the mannitol group. The remaining 25 patients were matched 1:1. Twenty-four patients received 3% HTS, and 1 received 23.4% HTS as bolus therapy. All 25 patients in the mannitol group received 20% mannitol. The mean cumulative ICP burden (15.52% [HTS] vs 36.5% [mannitol]; p = 0.003) and the mean (± SD) daily ICP burden (0.3 ± 0.6 hours/day [HTS] vs 1.3 ± 1.3 hours/day [mannitol]; p = 0.001) were significantly lower in the HTS group. The mean (± SD) number of ICU days was significantly lower in the HTS group than in the mannitol group (8.5 ± 2.1 vs 9.8 ± 0.6, respectively; p = 0.004), whereas there was no difference in the numbers of days of ICP monitoring (p = 0.09). There were no significant differences between the cumulative median doses of HTS and mannitol (p = 0.19). The 2-week mortality rate was lower in the HTS group, but the difference was not statistically significant (p = 0.56). CONCLUSIONS: HTS given as bolus therapy was more effective than mannitol in lowering the cumulative and daily ICP burdens after severe TBI. Patients in the HTS group had significantly lower number of ICU days. The 2-week mortality rates were not statistically different between the 2 groups. SN - 1933-0693 UR - https://www.unboundmedicine.com/medline/citation/25380107/Hypertonic_saline_reduces_cumulative_and_daily_intracranial_pressure_burdens_after_severe_traumatic_brain_injury_ L2 - https://thejns.org/doi/10.3171/2014.10.JNS132545 DB - PRIME DP - Unbound Medicine ER -