Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: A meta-analysis of randomized clinical trials*

Kamel, Hooman; Navi, Babak B.; Nakagawa, Kazuma; Hemphill, J. Claude; Ko, Nerissa

doi:10.1097/ccm.0b013e318206b9be

Cited by 312 publications

(159 citation statements)

References 44 publications

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“…One review, as with ours, concluded that hypertonic saline solution has no effect on mortality 21 ; another study reporting on mortality suggested a decreased mortality with the use of hypertonic saline. 16 With regards to the five systematic reviews evaluating intracranial pressure management, they identified a reduction in intracranial pressure [16][17][18][19][20] associated with hypertonic saline solution, in contrast with our results. These discrepancies may be due to several factors.…”

Section: Discussioncontrasting

confidence: 77%

“…[16][17][18][19][20][21] All reviews posed a different clinical question and used different inclusion criteria. One review, as with ours, concluded that hypertonic saline solution has no effect on mortality 21 ; another study reporting on mortality suggested a decreased mortality with the use of hypertonic saline.…”

Section: Discussionmentioning

confidence: 99%

“…Two reviews 18,19 included all study designs (retrospective, observational, randomized controlled trials). Four reviews [17][18][19][20] included several neurosurgical pathologies beyond severe traumatic brain injury (e.g., tumor, stroke). By only including randomized controlled trials of patients with severe traumatic brain injury, we achieved less clinical heterogeneity.…”

Section: Discussionmentioning

confidence: 99%

“…[13][14][15] Six systematic reviews aiming to evaluate the effect of hypertonic saline in neurocritically ill patients have been published showing inconsistent results. [16][17][18][19][20][21] However, these systematic reviews have important methodological flaws, notably the inclusion of studies with different designs and search strategies with low sensitivity. Furthermore, these reviews did not include the most recent publications.…”

Section: Introductionmentioning

confidence: 99%

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Hypertonic saline in severe traumatic brain injury: a systematic review and meta-analysis of randomized controlled trials

Berger-Pelleiter

Émond

Lauzier

et al. 2016

CJEM

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Objectives: Hypertonic saline solutions are increasingly used to treat increased intracranial pressure following severe traumatic brain injury. However, whether hypertonic saline provides superior management of intracranial pressure and improves outcome is unclear. We thus conducted a systematic review to evaluate the effect of hypertonic saline in patients with severe traumatic brain injury. Methods: Two researchers independently selected randomized controlled trials studying hypertonic saline in severe traumatic brain injury and collected data using a standardized abstraction form. No language restriction was applied. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and BIOSIS databases. We searched grey literature via OpenGrey and National Technical Information Service databases. We searched the references of included studies and relevant reviews for additional studies.Results: Eleven studies (1,820 patients) were included. Hypertonic saline did not decrease mortality (risk ratio 0.96, 95% confidence interval [CI] 0.83 to 1.11, I 2 = 0%) or improve intracranial pressure control (weighted mean difference −1.25 mm Hg, 95% CI −4.18 to 1.68, I 2 = 78%) as compared to any other solutions. Only one study reported monitoring for adverse events with hypertonic saline, finding no significant differences between comparison groups. Conclusions: We observed no mortality benefit or effect on the control of intracranial pressure with the use of hypertonic saline when compared to other solutions. Based on the current level of evidence pertaining to mortality or control of intracranial pressure, hypertonic saline could thus not be recommended as a first-line agent for managing patients with severe traumatic brain injury. RÉSUMÉObjectifs: Les solutés salés hypertoniques sont de plus en plus utilisés dans le traitement de l'élévation de la pression intracrânienne par suite d'une lésion cérébrale traumatique grave. Toutefois, on ne sait pas avec certitude si les solutés salés hypertoniques sont plus efficaces que d'autres traitements dans l'abaissement de la pression intracrânienne et s'ils donnent de meilleurs résultats. Les auteurs ont donc entrepris une revue systématique de la documentation afin d'évaluer l'effet des solutés salés hypertoniques chez les patients ayant subi une lésion cérébrale traumatique grave. Méthode: Deux chercheurs ont sélectionné chacun de leur côté des essais comparatifs à répartition aléatoire portant sur l'utilisation du soluté salé hypertonique dans le traitement des lésions cérébrales traumatiques graves, et ont recueilli des données sur un formulaire normalisé de résumé analytique. Aucune restriction de langue n'a été appliquée. Des recherches ont été effectuées dans les bases de données Medline, Embase, Cochrane Central Register of Controlled Trials, Scopus, Web of Science et Biosis. Les auteurs ont également consulté la documentation parallèle en passant par les bases de données OpenGrey et National Technical Information Service. Enfi...

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Section: Discussioncontrasting

confidence: 77%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Hypertonic saline in severe traumatic brain injury: a systematic review and meta-analysis of randomized controlled trials

Berger-Pelleiter

Émond

Lauzier

et al. 2016

CJEM

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“…Hyperosmolar therapy with either hypertonic saline or mannitol should be considered in cases where mass effect from significant edema is noted. We favor hypertonic saline over mannitol and, though no randomized clinical trials exist, a meta-analysis has supported this practice [138]. Two percent sodium (Na) solution can be given through a peripheral line, while 3 % or 23.4 % Na should be given through a central line.…”

Section: Edema and Herniationmentioning

confidence: 99%

Herpes Simplex Virus-1 Encephalitis in Adults: Pathophysiology, Diagnosis, and Management

2016

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Herpetic infections have plagued humanity for thousands of years, but only recently have advances in antiviral medications and supportive treatments equipped physicians to combat the most severe manifestations of disease. Prompt recognition and treatment can be lifesaving in the care of patients with herpes simplex-1 virus encephalitis, the most commonly identified cause of sporadic encephalitis worldwide. Clinicians should be able to recognize the clinical signs and symptoms of the infection and familiarize themselves with a rational diagnostic approach and therapeutic modalities, as early recognition and treatment are key to improving outcomes. Clinicians should also be vigilant for the development of acute complications, including cerebral edema and status epilepticus, as well as chronic complications, including the development of autoimmune encephalitis associated with antibodies to the N-methyl-D-aspartate receptor and other neuronal cell surface and synaptic epitopes. Herein, we review the pathophysiology, differential diagnosis, and clinical and radiological features of herpes simplex virus-1 encephalitis in adults, including a discussion of the most common complications and their treatment. While great progress has been made in the treatment of this life-threatening infection, a majority of patients will not return to their previous neurologic baseline, indicating the need for further research efforts aimed at improving the long-term sequelae.

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Effect of Continuous Infusion of Hypertonic Saline vs Standard Care on 6-Month Neurological Outcomes in Patients With Traumatic Brain Injury

Roquilly

Moyer

Huet

et al. 2021

JAMA

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for the Atlanrea Study Group and the Société Française d'Anesthésie Réanimation (SFAR) Research Network IMPORTANCE Fluid therapy is an important component of care for patients with traumatic brain injury, but whether it modulates clinical outcomes remains unclear.OBJECTIVE To determine whether continuous infusion of hypertonic saline solution improves neurological outcome at 6 months in patients with traumatic brain injury. DESIGN, SETTING, AND PARTICIPANTSMulticenter randomized clinical trial conducted in 9 intensive care units in France, including 370 patients with moderate to severe traumatic brain injury who were recruited from October 2017 to August 2019. Follow-up was completed in February 2020.INTERVENTIONS Adult patients with moderate to severe traumatic brain injury were randomly assigned to receive continuous infusion of 20% hypertonic saline solution plus standard care (n = 185) or standard care alone (controls; n = 185). The 20% hypertonic saline solution was administered for 48 hours or longer if patients remained at risk of intracranial hypertension. MAIN OUTCOMES AND MEASURESThe primary outcome was Extended Glasgow Outcome Scale (GOS-E) score (range, 1-8, with lower scores indicating worse functional outcome) at 6 months, obtained centrally by blinded assessors and analyzed with ordinal logistic regression adjusted for prespecified prognostic factors (with a common odds ratio [OR] >1.0 favoring intervention). There were 12 secondary outcomes measured at multiple time points, including development of intracranial hypertension and 6-month mortality. RESULTS Among 370 patients who were randomized (median age, 44 [interquartile range, 27-59] years; 77 [20.2%] women), 359 (97%) completed the trial. The adjusted common OR for the GOS-E score at 6 months was 1.02 (95% CI, 0.71-1.47; P = .92). Of the 12 secondary outcomes, 10 were not significantly different. Intracranial hypertension developed in 62 (33.7%) patients in the intervention group and 66 (36.3%) patients in the control group (absolute difference, −2.6% [95% CI, −12.3% to 7.2%]; OR, 0.80 [95% CI, 0.51-1.26]). There was no significant difference in 6-month mortality (29 [15.9%] in the intervention group vs 37 [20.8%] in the control group; absolute difference, −4.9% [95% CI, −12.8% to 3.1%]; hazard ratio, 0.79 [95% CI, 0.48-1.28]).CONCLUSIONS AND RELEVANCE Among patients with moderate to severe traumatic brain injury, treatment with continuous infusion of 20% hypertonic saline compared with standard care did not result in a significantly better neurological status at 6 months. However, confidence intervals for the findings were wide, and the study may have had limited power to detect a clinically important difference.

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Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: A meta-analysis of randomized clinical trials*

Cited by 312 publications

References 44 publications

Hypertonic saline in severe traumatic brain injury: a systematic review and meta-analysis of randomized controlled trials

Hypertonic saline in severe traumatic brain injury: a systematic review and meta-analysis of randomized controlled trials

Herpes Simplex Virus-1 Encephalitis in Adults: Pathophysiology, Diagnosis, and Management

Effect of Continuous Infusion of Hypertonic Saline vs Standard Care on 6-Month Neurological Outcomes in Patients With Traumatic Brain Injury

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