Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury

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 chisquare 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.http://thejns.org/doi/abs/10.3171/2014....

Hypertonic saline infusion suppresses apoptosis of hippocampal cells in a rat model of cardiopulmonary resuscitation

“…The close association of cerebral edema and brain neuronal cell apoptosis with increased permeability of blood brain barrier is well-documented 33 . Importantly, previous hypertonic saline infusion was shown to ameliorate the disruption of blood brain barrier, protect integrity of cerebral vasculature and attenuate vasogenic brain edema 34 , which indicates HS to be a good agent for reducing intracranial pressure 35 , improving cerebral perfusion and for lowering neuronal apoptosis. Additionally, hypertonic saline was shown to inhibit the expression of vascular endothelial growth factor (VEGF), which is closely related to cerebral vascular integrity and is known to regulate the permeability of blood brain barrier.…”

Postoperative care of the neurosurgical patient

“…After degradation and elimination of the mannitol molecules, osmotic equilibrium is reestablished. In contrast, bolus administration of hypertonic saline was more effective in lowering the cumulative and daily ICP burden after severe TBI and significantly reduced ICU length of stay [66]. Effectiveness of osmotic therapy depends on an intact blood-brain barrier.…”

Efficacy Comparison of Mannitol and Hypertonic Saline for Traumatic Brain Injury (TBI) Treatment

“…After the pairing, they included 25 patients in 20% mannitol group and 25 patients in hypertonic saline (3% hypertonic Saline n = 24; 23.4% hypertonic Saline, n = 1) with similar characteristics. 33 The study found that the number of days and the number of hours per days where a patient had ICP >25 mmHg was lower in hypertonic saline group compared to mannitol group. The authors also found that patient in hypertonic saline group were hospitalized in ICU for shorter period.…”