Hypertonic saline for the management of raised intracranial pressure after severe traumatic brain injury

Abstract

Hyperosmolar agents are commonly used as an initial treatment for the management of raised intracranial pressure (ICP) after severe traumatic brain injury (TBI). They have an excellent adverse-effect profile compared to other therapies, such as hyperventilation and barbiturates, which carry the risk of reducing cerebral perfusion. The hyperosmolar agent mannitol has been used for several decades to reduce raised ICP, and there is accumulating evidence from pilot studies suggesting beneficial effects of hypertonic saline (HTS) for similar purposes. An ideal therapeutic agent for ICP reduction should reduce ICP while maintaining cerebral perfusion (pressure). While mannitol can cause dehydration over time, HTS helps maintain normovolemia and cerebral perfusion, a finding that has led to a large amount of pilot data being published on the benefits of HTS, albeit in small cohorts. Prophylactic therapy is not recommended with mannitol, although it may be beneficial with HTS. To date, no large clinical trial has been performed to directly compare the two agents. The best current evidence suggests that mannitol is effective in reducing ICP in the management of traumatic intracranial hypertension and carries mortality benefit compared to barbiturates. Current evidence regarding the use of HTS in severe TBI is limited to smaller studies, which illustrate a benefit in ICP reduction and perhaps mortality.

Monitoring intracranial pressure utilizing a novel pattern of brain multiparameters in the treatment of severe traumatic brain injury

“… 26 , 27 Mannitol is effective in reducing ICP in the management of traumatic intracranial hypertension and carries mortality benefit compared to barbiturates. 28 Although international guidance about the dosage of mannitol is from 0.25 g/kg to 1 g/kg, 29 , 30 there is no uniform dosage for clinical application for dehydration. In this study, we compared the efficiency of two different doses (25 g and 50 g) of mannitol by monitoring ICP in the condition of mild hypothermia.…”

Return on investment

“…Specifically, the management of sodium flux in the first 6 hours after injury may hold some hints for better outcome. 20,21 We and others have shown the benefit of posttraumatic intracranial hypertension rescue using 23.4% hypertonic saline as a 20-minute bolus equal to the 75% of the patient's body weight in milliliters delivered via central venous catheter, 22 yet very few institutions use this approach or even understand the difference between the literature assessing resuscitation with continuous infusion of 3%, 5%, or 7.5% saline. This is the perfect example of an opportunity for multiple institutions to collaborate and share data that disseminate this information, validate its effect, identify any negative events, and define principles of timing and use.…”

Comparative Evaluation of Efficacy of Mannitol and Hypertonic Saline (3%) for Treatment of Moderate to Severe Traumatic Brain Injury (TBI)

“…An ideal agent should stay within the intravascular component while it draws the fluid out of the brain [24]. The ideal agent used is one which lowers Intracranial Pressure (ICP) while also sustaining the Cerebral Perfusion Pressure (CPP) at the same level [25]. An ideal hyperosmolar agent is non-reactive, non-toxic and should not have any major unwanted effects [26].…”