Serum sodium and intracranial pressure changes after desmopressin therapy in severe traumatic brain injury patients: a multi-centre cohort study

Desmopressin Administration and Impact on Hypertonic Saline Effectiveness in Intracranial Hemorrhage

INTRODUCTION

Desmopressin improves hemostasis through the release of factor VIII, von Willebrand factor, and tissue plasminogen activator, and increases platelet adhesion. Neurocritical Care guidelines recommend consideration of desmopressin in antiplatelet-associated intracranial hemorrhage. Studies supporting its use have not evaluated the potential impact of desmopressin on serum sodium levels in patients receiving hypertonic saline therapy. The purpose of this study was to assess the impact of desmopressin on sodium levels and hypertonic saline effectiveness in intracranial hemorrhage.

METHODS

This was a single center retrospective observational chart review. Patients were included in the desmopressin group if they were diagnosed with intracranial hemorrhage, administered desmopressin, and received hypertonic saline infusion. Patients in the hypertonic saline alone group were then matched 1:1 to the patients in the desmopressin group. The primary end point was the effect of desmopressin on reaching a sodium goal of 145-155 mEq/L. The secondary end points included intensive care unit and hospital length of stay, change in sodium, time to reach sodium goal, thrombotic events, mortality, and a composite of increased cerebral edema, hematoma expansion, midline shift, herniation, need for neurosurgical intervention, and neurologic decompensation.

RESULTS

Of 112 patients screened, 25 patients met inclusion criteria for the desmopressin group, and 25 patients were matched with patients in the hypertonic saline alone group. The percentage of patients who reached goal sodium in the desmopressin group compared with hypertonic saline alone was similar (80% vs. 88%, respectively). There were no differences in the secondary end points. In the subgroup analysis, patients in the hypertonic saline group met the predefined sodium goal of 150-155 mEq/L within 48 h more often than those in the desmopressin group (82% vs. 60%, respectively, p = 0.042).

CONCLUSIONS

The use of desmopressin in intracranial hemorrhage does not appear to negatively impact the ability for patients to reach goal sodium of 145-155 mEq/L. However, in patients with higher sodium goals, desmopressin may decrease hypertonic saline effectiveness.

Hypernatremia and moderate-to-severe hyponatremia are independent predictors of mortality in septic patients at emergency department presentation: A sub-group analysis of the need-speed trial

STUDY OBJECTIVE

Early risk stratification of septic patients presenting to the emergency department (ED) is challenging. The aim of the study was to evaluate the prognostic role of plasmatic sodium level (_PNa⁺) derangements at ED presentation in septic patients.

METHODS

According to _PNa⁺ at ED presentation patients were divided in eunatremic (136-145 mEq/L), hypernatremic (>145 mEq/L) and hyponatremic (<136 mEq/L). Hyponatremic patients were subsequently divided in mild (130-135 mEq/L), moderate (125-129 mEq/L) and severe (<125 mEq/L). 7 and 30-day mortality was evaluated according to _PNa⁺ derangements and the degree of hyponatremia. The same analysis was then performed only in respiratory tract infection-related (RTI-r) sepsis patients.

RESULTS

879 septic patients were included in this analysis, 40.3% had hyponatremia, 5.7% hypernatremia. Hypernatremia showed higher mortality rates at both endpoints compared to eunatremia and hyponatremia (p<0.0001 for both). Eunatremia and mild hyponatremia were compared vs. moderate-to-severe hyponatremia showing a significant difference in terms of 7 and 30-day survival (p = 0.004 and p = 0.007, respectively). The Cox proportional model identified as independent predictors of 7 and 30-day mortality moderate-to-severe hyponatremia (HR 4.89[2.38-10.03] and 1.79[1.07-3.01], respectively) and hypernatremia (HR 3.52[1.58-7.82] and 2.14[1.17-3.92], respectively). The same analysis was performed in patients with respiratory tract infection-related sepsis (n = 549), with similar results.

CONCLUSION

Both hypernatremia and moderate-to-severe hyponatremia at ED presentation independently predict mortality in septic patients, allowing early risk stratification and suggesting more aggressive therapeutic strategies.

Variability in Serum Sodium Concentration and Prognostic Significance in Severe Traumatic Brain Injury: A Multicenter Observational Study

BACKGROUND/OBJECTIVE

Dysnatremia is common in severe traumatic brain injury (TBI) patients and may contribute to mortality. However, serum sodium variability has not been studied in TBI patients. We hypothesized that such variability would be independently associated with mortality.

METHODS

We collected 6-hourly serum sodium levels for the first 7 days of ICU admission from 240 severe TBI patients in 14 neurotrauma ICUs in Europe and Australia. We evaluated the association between daily serum sodium standard deviation (dNa_SD), an index of variability, and 28-day mortality.

RESULTS

Patients were 46 ± 19 years of age with a median initial GCS of 6 [4-8]. Overall hospital mortality was 28%. Hypernatremia and hyponatremia occurred in 64% and 24% of patients, respectively. Over the first 7 days in ICU, serum sodium standard deviation was 2.8 [2.0-3.9] mmol/L. Maximum daily serum sodium standard deviation (dNa_SD) occurred at a median of 2 [1-4] days after admission. There was a significant progressive decrease in dNa_SD over the first 7 days (coefficient - 0.15 95% CI [- 0.18 to - 0.12], p < 0.001). After adjusting for baseline TBI severity, diabetes insipidus, the use of osmotherapy, the occurrence of hypernatremia, and hyponatremia and center, dNa_SD was significantly independently associated with 28-day mortality (HR 1.27 95% CI (1.01-1.61), p = 0.048).

CONCLUSIONS

Our study demonstrates that daily serum sodium variability is an independent predictor of 28-day mortality in severe TBI patients. Further prospective investigations are necessary to confirm the significance of sodium variability in larger cohorts of TBI patients and test whether attenuating such variability confers outcome benefits to such patients.