Hypertonic saline versus other intracranial pressure-lowering agents for people with acute traumatic brain injury

Chen, Han; Song, Zhi; Dennis, Jane A

doi:10.1002/14651858.cd010904.pub3

Cited by 36 publications

(23 citation statements)

References 59 publications

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“…The implications of this on final outcome of these patients remain unclear: although a (prolonged) raised ICP has been shown to be associated with a worse outcome, a proven survival benefit has never been established for hyperosmolar therapy in patients with TBI. [18][19][20] As we found that specificity of clinical signs for a raised ICP is high, overtreatment (with a resulting risk of development of acute heart failure, pulmonary oedema and the possibility of developing central pontine myelinosis) 21 is less of a concern when treatment guidelines are followed.…”

Section: Discussionmentioning

confidence: 77%

Prehospital clinical signs are a poor predictor of raised intracranial pressure following traumatic brain injury

Avest¹,

Sh²,

Wilson

et al. 2020

Emerg Med J

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BackgroundFor the prehospital diagnosis of raised intracranial pressure (ICP), clinicians are reliant on clinical signs such as the Glasgow Coma Score (GCS), pupillary response and/or Cushing’s triad (hypertension, bradycardia and an irregular breathing pattern). This study aimed to explore the diagnostic accuracy of these signs as indicators of a raised ICP.MethodsWe performed a retrospective cohort study of adult patients attended by a Helicopter Emergency Medical Service (Air Ambulance Kent, Surrey Sussex), who had sustained a traumatic brain injury (TBI), requiring prehospital anaesthesia between 1 January 2016 and 1 January 2018. We established optimal cut-off values for clinical signs to identify patients with a raised ICP and investigated diagnostic accuracy for combinations of these values.ResultsOutcome data for 249 patients with TBI were available, of which 87 (35%) had a raised ICP. Optimal cut-off points for systolic blood pressure (SBP), heart rate (HR) and pupil diameter to discriminate patients with a raised ICP were, respectively, >160 mm Hg,<60 bpm and >5 mm. Cushing criteria (SBP >160 mm Hg and HR <60 bpm) and pupillary response and size were complimentary in their ability to detect patients with a raised ICP. The presence of a fixed blown pupil or a Cushing’s response had a specificity of 93.2 (88.2–96.6)%, and a positive likelihood ratio (LR+) of 5.4 (2.9–10.2), whereas sensitivity and LR− were only 36.8 (26.7–47.8)% and 0.7 (0.6–0.8), respectively, (Area Under the Curve (AUC) 0.65 (0.57–0.73)). Sensitivity analysis revealed that optimal cut-off values and resultant accuracy were dependent on injury pattern.ConclusionTraditional clinical signs of raised ICP may under triage patients to prehospital treatment with hyperosmolar drugs. Further research should identify more accurate clinical signs or alternative non-invasive diagnostic aids in the prehospital environment.

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Section: Discussionmentioning

confidence: 77%

Prehospital clinical signs are a poor predictor of raised intracranial pressure following traumatic brain injury

Avest¹,

Sh²,

Wilson

et al. 2020

Emerg Med J

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“…Though mannitol has long-been the workhorse hyperosmolar therapy, a growing body of literature suggests that hypertonic saline is also effective in treating elevated intracranial pressure from a variety of causes (12). Although it has been suggested that hypertonic saline may be superior to mannitol in terms of rate, duration, effect size, and side effect profile, controversy remains (13)(14)(15)(16)(17)(18)(19).…”

Section: Discussionmentioning

confidence: 99%

An Audit and Comparison of pH, Measured Concentration, and Particulate Matter in Mannitol and Hypertonic Saline Solutions

et al. 2021

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Background: The preferred hyperosmolar therapy remains controversial. Differences in physical properties such as pH and osmolality may be important considerations in hyperosmolar agent selection. We aimed to characterize important physical properties of commercially available hyperosmolar solutions.Methods: We measured pH and concentration in 37 commonly-used hyperosmolar solutions, including 20 and 25% mannitol and 3, 5, 14.6, and 23.4% hypertonic saline. pH was determined digitally and with litmus paper. Concentration was determined by freezing point and vapor pressure osmometry. Salinity/specific gravity was measured with portable refractometry. Particulate matter was analyzed with filtration and light microscopy and with dynamic light scattering nephelometry.Results: pH of all solutions was below physiological range (measured range 4.13–6.80); there was no correlation between pH and solution concentration (R2 = 0.005, p = 0.60). Mannitol (mean 5.65, sd 0.94) was less acidic than hypertonic saline (5.16, 0.60). 14/59 (24%) pH measurements and 85/111 concentration measurements were outside manufacturer standards. All 36/36 mannitol concentration measurements were outside standards vs. 48/72 (67%) hypertonic saline (p < 0.0001). All solutions examined on light microscopy contained crystalline and/or non-crystalline particulate matter up to several hundred microns in diameter. From nephelometry, particulate matter was detected in 20/22 (91%) solutions.Conclusion: We present a novel characterization of mannitol and hypertonic saline. Further research should be undertaken, including research examining development of acidosis following hyperosmolar therapy, the relevance of our findings for dose-response, and the clinical relevance of particulate matter in solution.

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“…Numerous reviews and meta-analyses evaluate HTS and mannitol against various agents in the human clinical literature (33,62,(72)(73)(74)(75)(76)(77)(78)(79)(80)(81)(82). In summary, the studies are heterogenous in population, dose, concentration and rate of fluid administered, therapeutic targets, and outcomes of interest.…”

Section: Managing Elevated Icp With Osmotherapymentioning

confidence: 99%

“…A rebound phenomenon was defined in a Cochrane review by Chen (76) et al as 'intracranial pressure rising above its original level after hyperosmolar therapy.' However, the rebound phenomenon occurring in patients with TBI is only mentioned in passing in a single study included in the Cochrane review (76) and in the veterinary pilot study (71). Despite effective reduction of ICP, neither HTS nor mannitol has clinical evidence supporting improved survival or long-term neurologic outcome (33,75,81).…”

Section: Managing Elevated Icp With Osmotherapymentioning

confidence: 99%

Traumatic Brain Injury—A Review of Intravenous Fluid Therapy

Pigott¹,

Rudloff²

2021

Front. Vet. Sci.

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Hypertonic saline versus other intracranial pressure-lowering agents for people with acute traumatic brain injury

Abstract: Hypertonic saline versus other intracranial pressure-lowering agents for people with acute traumatic brain injury.

Cited by 36 publications

References 59 publications

Prehospital clinical signs are a poor predictor of raised intracranial pressure following traumatic brain injury

Prehospital clinical signs are a poor predictor of raised intracranial pressure following traumatic brain injury

An Audit and Comparison of pH, Measured Concentration, and Particulate Matter in Mannitol and Hypertonic Saline Solutions

Traumatic Brain Injury—A Review of Intravenous Fluid Therapy

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