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Codorniu A, Charbit E, Werner M, James A, Hanouz JL, Jost D, Severin A, Lang E, Pottecher J, Favreau M, Weiss E, Abback PS, Moyer JD. Comparison of mannitol and hypertonic saline solution for the treatment of suspected brain herniation during prehospital management of traumatic brain injury patients. Eur J Emerg Med 2024; 31:287-293. [PMID: 38691014 DOI: 10.1097/mej.0000000000001138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
BACKGROUND AND IMPORTANCE Occurrence of mydriasis during the prehospital management of traumatic brain injury (TBI) may suggest severe intracranial hypertension (ICH) subsequent to brain herniation. The initiation of hyperosmolar therapy to reduce ICH and brain herniation is recommended. Whether mannitol or hypertonic saline solution (HSS) should be preferred is unknown. OBJECTIVES The objective of this study is to assess whether HSS, compared with mannitol, is associated with improved survival in adult trauma patients with TBI and mydriasis. DESIGN/SETTING AND PARTICIPANTS A retrospective observational cohort study using the French Traumabase national registry to compare the ICU mortality of patients receiving either HSS or mannitol. Patients aged 16 years or older with moderate to severe TBI who presented with mydriasis during prehospital management were included. OUTCOME MEASURES AND ANALYSIS We performed propensity score matching on a priori selected variables [i.e. age, sex and initial Coma Glasgow Scale (GCS)] with a ratio of 1 : 3 to ensure comparability between the two groups. The primary outcome was ICU mortality. The secondary outcomes were regression of pupillary abnormality during prehospital management, pulsatility index and diastolic velocity on transcranial Doppler within 24 h after TBI, early ICU mortality (within 48 h), ICU and hospital length of stay. RESULTS Of 31 579 patients recorded in the registry between 2011 and 2021, 1417 presented with prehospital mydriasis and were included: 1172 (82.7%) received mannitol and 245 (17.3%) received HSS. After propensity score matching, 720 in the mannitol group matched 240 patients in the HSS group. Median age was 41 years [interquartile ranges (IQR) 26-60], 1058 were men (73%) and median GCS was 4 (IQR 3-6). No significant difference was observed in terms of characteristics and prehospital management between the two groups. ICU mortality was lower in the HSS group (45%) than in the mannitol group (54%) after matching [odds ratio (OR) 0.68 (0.5-0.9), P = 0.014]. No differences were identified between the groups in terms of secondary outcomes. CONCLUSION In this propensity-matched observational study, the prehospital osmotherapy with HSS in TBI patients with prehospital mydriasis was associated with a lower ICU mortality compared to osmotherapy with mannitol.
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Affiliation(s)
- Anais Codorniu
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Paris
| | - Emilie Charbit
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Paris
| | - Marie Werner
- Department of Anesthesiology and Critical Care, APH-HP, Bicêtre Hôpitaux Universitaires Paris-Saclay, Université Paris Saclay, Le Kremlin Bicêtre
| | - Arthur James
- Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris
| | - Jean-Luc Hanouz
- Department of Anesthesiology and Critical Care Medicine, Caen University Hospital, Avenue de la cote de Nacre, Caen
| | - Daniel Jost
- Emergency Medical Department, Fire Brigade of Paris
| | - Armelle Severin
- SAMU des Hauts-de-Seine - SMUR Raymond Poincaré, Raymond Poincaré Hospital, Paris Saclay University, Assistance Publique-Hôpitaux de Paris (APHP)
| | - Elodie Lang
- Department of Anaesthesia and Critical Care, AP-HP, Hôpital Européen Georges Pompidou, Paris Cité University, Paris
| | - Julien Pottecher
- Department of Anaesthesiology, Critical Care and Perioperative Medicine, Fédération de Médecine Translationnelle de Strasbourg, ER 3072, Strasbourg University Hospital, Strasbourg
| | - Malory Favreau
- Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris
| | - Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Paris
| | - Paer Selim Abback
- Department of Anesthesiology and Critical Care Medicine, CHU Tours, Tours University Hospital, Tours, France
| | - Jean-Denis Moyer
- Department of Anesthesiology and Critical Care Medicine, Caen University Hospital, Avenue de la cote de Nacre, Caen
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Navarro JC, Kofke WA. Perioperative Management of Acute Central Nervous System Injury. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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3
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Battaglini D, Anania P, Rocco PRM, Brunetti I, Prior A, Zona G, Pelosi P, Fiaschi P. Escalate and De-Escalate Therapies for Intracranial Pressure Control in Traumatic Brain Injury. Front Neurol 2020; 11:564751. [PMID: 33324317 PMCID: PMC7724991 DOI: 10.3389/fneur.2020.564751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 10/30/2020] [Indexed: 12/22/2022] Open
Abstract
Severe traumatic brain injury (TBI) is frequently associated with an elevation of intracranial pressure (ICP), followed by cerebral perfusion pressure (CPP) reduction. Invasive monitoring of ICP is recommended to guide a step-by-step “staircase approach” which aims to normalize ICP values and reduce the risks of secondary damage. However, if such monitoring is not available clinical examination and radiological criteria should be used. A major concern is how to taper the therapies employed for ICP control. The aim of this manuscript is to review the criteria for escalating and withdrawing therapies in TBI patients. Each step of the staircase approach carries a risk of adverse effects related to the duration of treatment. Tapering of barbiturates should start once ICP control has been achieved for at least 24 h, although a period of 2–12 days is often required. Administration of hyperosmolar fluids should be avoided if ICP is normal. Sedation should be reduced after at least 24 h of controlled ICP to allow neurological examination. Removal of invasive ICP monitoring is suggested after 72 h of normal ICP. For patients who have undergone surgical decompression, cranioplasty represents the final step, and an earlier cranioplasty (15–90 days after decompression) seems to reduce the rate of infection, seizures, and hydrocephalus.
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Affiliation(s)
- Denise Battaglini
- Department of Anesthesia and Intensive Care, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy
| | - Pasquale Anania
- Department of Neurosurgery, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Rio de Janeiro Network on Neuroinflammation, Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil.,Rio de Janeiro Innovation Network in Nanosystems for Health-Nano SAÚDE/Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil
| | - Iole Brunetti
- Department of Anesthesia and Intensive Care, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy
| | - Alessandro Prior
- Department of Neurosurgery, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy
| | - Gianluigi Zona
- Department of Neurosurgery, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy.,Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Paolo Pelosi
- Department of Anesthesia and Intensive Care, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Sciences and Integral Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Pietro Fiaschi
- Department of Neurosurgery, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy.,Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
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4
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Bernstein JE, Ghanchi H, Kashyap S, Podkovik S, Miulli DE, Wacker MR, Sweiss R. Pentobarbital Coma With Therapeutic Hypothermia for Treatment of Refractory Intracranial Hypertension in Traumatic Brain Injury Patients: A Single Institution Experience. Cureus 2020; 12:e10591. [PMID: 33110727 PMCID: PMC7581220 DOI: 10.7759/cureus.10591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Introduction Traumatic brain injury (TBI) results in primary and secondary brain injuries. Secondary brain injury can lead to cerebral edema resulting in increased intracranial pressure (ICP) secondary to the rigid encasement of the skull. Increased ICP leads to decreased cerebral perfusion pressure which leads to cerebral ischemia. Refractory intracranial hypertension (RICH) occurs when ICP remains elevated despite first-tier therapies such as head elevation, straightening of the neck, analgesia, sedation, paralytics, cerebrospinal fluid (CSF) drainage, mannitol and/or hypertonic saline administration. If unresponsive to these measures, second-tier therapies such as hypothermia, barbiturate infusion, and/or surgery are employed. Methods This was a retrospective review of patients admitted at Arrowhead Regional Medical Center from 2008 to 2019 for severe TBI who developed RICH requiring placement into a pentobarbital-induced coma with therapeutic hypothermia. Primary endpoints included mortality, good recovery which was designated at Glasgow outcome scale (GOS) of 4 or 5, and improvement in ICP (goal is <20 mmHg). Secondary endpoints included complications, length of intensive care unit (ICU) stay, length of hospital stay, length of pentobarbital coma, length of hypothermia, need for vasopressors, and decompressive surgery versus no decompressive surgery. Results Our study included 18 patients placed in pentobarbital coma with hypothermia for RICH. The overall mortality rate in our study was 50%; with 60% mortality in pentobarbital/hypothermia only group, and 46% mortality in surgery plus pentobarbital/hypothermia group. Maximum ICP prior to pentobarbital/hypothermia was significantly lower in patients who had a prior decompressive craniectomy than in patients who were placed into pentobarbital/hypothermia protocol first (28.3 vs 35.4, p<0.0238). ICP was significantly reduced at 4 hours, 8 hours, 12 hours, 24 hours, and 48 hours after pentobarbital and hypothermia treatment. Initial ICP and maximum ICP prior to pentobarbital/hypothermia was significantly correlated with mortality (p=0.022 and p=0.026). Patients with an ICP>25 mmHg prior to pentobarbital/hypothermia initiation had an increased risk of mortality (p=0.0455). There was no statistically significant difference in mean ICP after 24 hours after pentobarbital/hypothermia protocol in survivors vs non-survivors. Increased time to reach 33°C was associated with increased mortality (r=0.47, p=0.047); with a 10.5-fold increase in mortality for >7 hours (OR 10.5, p=0.039). Conclusion Prolonged cooling time >7 hours was associated with a 10.5-fold increase in mortality and ICP>25 mmHg prior to initiation of pentobarbital and hypothermia is suggestive of a poor response to treatment. We recommend patients with severe TBI who develop RICH should first undergo a 12 x 15 cm decompressive hemicraniectomy because they have better survival and are more likely to have ICP <25 mmHg as the highest elevation of ICP if the ICP were to become and stay elevated again. Pentobarbital and hypothermia should be initiated if the ICP becomes elevated and sustained above 20 mmHg with a prior decompressive hemicraniectomy and refractory to other medical therapies. However, our data suggests that patients are unlikely to survive if there ICP does not decrease to less than 15mmHg at 8 and 12 hours after pentobarbital/hypothermia and remain less than 20 mmHg within first 48 hours.
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Affiliation(s)
- Jacob E Bernstein
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Hammad Ghanchi
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Samir Kashyap
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Stacey Podkovik
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Dan E Miulli
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
| | | | - Raed Sweiss
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
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5
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Mangat HS, Wu X, Gerber LM, Schwarz JT, Fakhar M, Murthy SB, Stieg PE, Ghajar J, Härtl R. Hypertonic Saline is Superior to Mannitol for the Combined Effect on Intracranial Pressure and Cerebral Perfusion Pressure Burdens in Patients With Severe Traumatic Brain Injury. Neurosurgery 2020; 86:221-230. [PMID: 30877299 DOI: 10.1093/neuros/nyz046] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 01/31/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Hypertonic saline (HTS) and mannitol are effective in reducing intracranial pressure (ICP) after severe traumatic brain injury (TBI). However, their simultaneous effect on the cerebral perfusion pressure (CPP) and ICP has not been studied rigorously. OBJECTIVE To determine the difference in effects of HTS and mannitol on the combined burden of high ICP and low CPP in patients with severe TBI. METHODS We performed a case-control study using prospectively collected data from the New York State TBI-trac® database (Brain Trauma Foundation, New York, New York). Patients who received only 1 hyperosmotic agent, either mannitol or HTS for raised ICP, were included. Patients in the 2 groups were matched (1:1 and 1:2) for factors associated with 2-wk mortality: age, Glasgow Coma Scale score, pupillary reactivity, hypotension, abnormal computed tomography scans, and craniotomy. Primary endpoint was the combined burden of ICPhigh (> 25 mm Hg) and CPPlow (< 60 mm Hg). RESULTS There were 25 matched pairs for 1:1 comparison and 24 HTS patients matched to 48 mannitol patients in 1:2 comparisons. Cumulative median osmolar doses in the 2 groups were similar. In patients treated with HTS compared to mannitol, total number of days (0.6 ± 0.8 vs 2.4 ± 2.3 d, P < .01), percentage of days with (8.8 ± 10.6 vs 28.1 ± 26.9%, P < .01), and the total duration of ICPhigh + CPPlow (11.12 ± 14.11 vs 30.56 ± 31.89 h, P = .01) were significantly lower. These results were replicated in the 1:2 match comparisons. CONCLUSION HTS bolus therapy appears to be superior to mannitol in reduction of the combined burden of intracranial hypertension and associated hypoperfusion in severe TBI patients.
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Affiliation(s)
- Halinder S Mangat
- Department of Neurology, Weill Cornell Medicine, New York, New York.,Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, New York
| | - Xian Wu
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York
| | - Linda M Gerber
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York
| | - Justin T Schwarz
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, New York.,NewYork-Presbyterian Hospital, New York, New York
| | - Malik Fakhar
- Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Santosh B Murthy
- Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Philip E Stieg
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, New York
| | - Jamshid Ghajar
- Department of Neurological Surgery, Stanford University, Palo Alto, California.,Brain Trauma Foundation, New York, New York
| | - Roger Härtl
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, New York
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6
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Examining the Effect of Hypertonic Saline Administered for Reduction of Intracranial Hypertension on Coagulation. J Am Coll Surg 2019; 230:322-330.e2. [PMID: 31843691 DOI: 10.1016/j.jamcollsurg.2019.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/18/2019] [Accepted: 11/19/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Hypertonic saline (23.4%, HTS) bolus administration is common practice for refractory intracranial hypertension, but its effects on coagulation are unknown. We hypothesize that 23.4% HTS in whole blood results in progressive impairment of coagulation in vitro and in vivo in a murine model of traumatic brain injury (TBI). STUDY DESIGN For the in vitro study, whole blood was collected from 10 healthy volunteers, and citrated native thrombelastography was performed with normal saline (0.9%, NS) and 23.4% HTS in serial dilutions (2.5%, 5%, and 10%). For the in vivo experiment, we assessed the effects of 23.4% HTS bolus vs NS on serial thrombelastography and tail-bleeding times in a TBI murine model (n = 10 rats with TBI and 10 controls). RESULTS For the in vitro work, clinically relevant concentrations of HTS (2.5% dilution) shortened time to clot formation and increased clot strength (maximum amplitude) compared with control and NS. With higher HTS dosing (5% and 10% blood dilution), there was progressive prolongation of time to clot formation, decreased angle, and decreased maximum amplitude. In the in vivo study, there was no significant difference in thrombelastography measurements or tail-bleeding times after bolus administration of 23.4% HTS compared with NS at 2.5% blood volume. CONCLUSIONS At clinically relevant dilutions of HTS, there is a paradoxical shortening of time to clot formation and increase in clot strength in vitro and no significant effects in a murine TBI model. However, with excess dilution, caution should be exercised when using serial HTS boluses in TBI patients at risk for trauma-induced coagulopathy.
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7
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Gu J, Huang H, Huang Y, Sun H, Xu H. Hypertonic saline or mannitol for treating elevated intracranial pressure in traumatic brain injury: a meta-analysis of randomized controlled trials. Neurosurg Rev 2019; 42:499-509. [PMID: 29905883 DOI: 10.1007/s10143-018-0991-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 05/05/2018] [Accepted: 06/04/2018] [Indexed: 02/05/2023]
Abstract
Hyperosmolar therapy is regarded as the mainstay for treatment of elevated intracranial pressure (ICP) in traumatic brain injury (TBI). This still has been disputed as application of hypertonic saline (HS) or mannitol for treating patients with severe TBI. Thus, this meta-analysis was performed to further compare the advantages and disadvantages of mannitol with HS for treating elevated ICP after TBI. We conducted a systematic search on PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Wan Fang Data, VIP Data, SinoMed, and China National Knowledge Infrastructure (CNKI) databases. Studies were included or not based on the quality assessment by the Jadad scale and selection criteria. Twelve RCTs with 438 patients were enrolled for the meta-analysis. The comparison of HS and mannitol indicated that they were close in field of improving function outcome (RR = 1.17, 95% CI 0.89 to 1.54, p = 0.258) and reducing intracranial pressure (MD = - 0.16, 95% CI: - 0.59 to 0.27, p = 0.473) and mortality (RR = 0.78, 95% CI 0.53 to 1.16, p = 0.216). The pooled relative risk of successful ICP control was 1.06 (95% CI: 1.00 to 1.13, p = 0.044), demonstrating that HS was more effective than mannitol in ICP management. Both serum sodium (WMD = 5.30, 95% CI: 4.37 to 6.22, p < 0.001) and osmolality (WMD = 3.03, 95% CI: 0.18 to 5.88, p = 0.037) were increased after injection of hypertonic saline. The results do not lend a specific recommendation to select hypertonic saline or mannitol as a first-line for the patients with elevated ICP caused by TBI. However, for the refractory intracranial hypertension, hypertonic saline seems to be preferred.
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Affiliation(s)
- Jiajie Gu
- College of Medicine, Shantou University, Shantou, Guangdong, China
| | - Haoping Huang
- College of Medicine, Shantou University, Shantou, Guangdong, China
| | - Yuejun Huang
- Transforming Medical Center, Second Affiliated Hospital of Medical College of Shantou University, North Dongxia Rd, Shantou, 515041, Guangdong, China
| | - Haitao Sun
- Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, China
| | - Hongwu Xu
- Department of Neurosurgery, The First Affiliated Hospital of Shantou University Medical College, Changping Rd, Shantou, 515041, Guangdong, China.
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8
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Cheng F, Xu M, Liu H, Wang W, Wang Z. A Retrospective Study of Intracranial Pressure in Head-Injured Patients Undergoing Decompressive Craniectomy: A Comparison of Hypertonic Saline and Mannitol. Front Neurol 2018; 9:631. [PMID: 30131757 PMCID: PMC6090152 DOI: 10.3389/fneur.2018.00631] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 07/12/2018] [Indexed: 11/13/2022] Open
Abstract
Objective: The impact of hypertonic saline (HTS) on the control of increased intracranial pressure (ICP) in head-injured patients undergoing decompressive craniectomy (DC) has yet to be established. The current retrospective study was conducted to compare the effect of HTS and mannitol on lowering the ICP burden of these patients. Methods: We reviewed data on patients who had sustained a traumatic brain injury (TBI) and were admitted to the First People's Hospital of Kunshan between January 1, 2012, and August 31, 2017. Patients who received only one type of hyperosmotic agent, 3% HTS or 20% mannitol, after DC were included. The daily ICP burden (h/day) and response to the hyperosmolar agent were used as primary outcome measures. The numbers of days in the intensive care unit and in the hospital, and the 2-weeks mortality rates were also compared between the groups. Results: The 30 patients who received 3% HTS only and the 30 who received 20% mannitol only were identified for approximate matching and additional data analyses. The demographic characteristics of the patients in the two groups were comparable, but the daily ICP burden was significantly lower in the HTS group than in the mannitol group (0.89 ± 1.02 h/day vs. 2.11 ± 2.95 h/day, respectively; P = 0.038). The slope of the reduction in ICP in response to a bolus dose at baseline was higher with HTS than with mannitol (P = 0.001). However, the between-group difference in the 2-weeks mortality rates was not statistically significant (2 [HTS] vs. 1 [mannitol]; P = 0.554). Conclusion: When used in equiosmolar doses, the reduction in the ICP of TBI patients achieved with 3% HTS was superior to that achieved with 20% mannitol after DC. However, this advantage did not seem to confer any additional benefit terms of short-term mortality.
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Affiliation(s)
- Feng Cheng
- Department of Neurosurgery, Suzhou Kowloon Hospital, Soochow University, Suzhou, China.,Department of Neurosurgery, The First People's Hospital of Kunshan, Jiangsu University, Suzhou, China
| | - Min Xu
- Department of Neurosurgery, Kunshan Hospital of Traditional Chinese Medicine, Suzhou, China
| | - Hua Liu
- Department of Neurosurgery, The First People's Hospital of Kunshan, Jiangsu University, Suzhou, China
| | - Wenming Wang
- Department of Neurosurgery, The First People's Hospital of Kunshan, Jiangsu University, Suzhou, China
| | - Zhimin Wang
- Department of Neurosurgery, Suzhou Kowloon Hospital, Soochow University, Suzhou, China
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9
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Fluid therapy in neurointensive care patients: ESICM consensus and clinical practice recommendations. Intensive Care Med 2018; 44:449-463. [DOI: 10.1007/s00134-018-5086-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 02/03/2018] [Indexed: 01/03/2023]
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10
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Chapman SA, Irwin ED, Thunselle M, Ronk A, Reicks P, Curran B, Rangarajan K, Tam H, Beilman GJ. Serum sodium response to hypertonic saline infusion therapy in traumatic brain injury. J Clin Neurosci 2017; 48:147-152. [PMID: 29153769 DOI: 10.1016/j.jocn.2017.10.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 10/23/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Scott A Chapman
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States.
| | - Eric D Irwin
- Division of Critical Care and Acute Care Surgery, Department of Surgery, School of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Matthew Thunselle
- Department of Pharmacy Services, North Memorial Medical Center, Robbinsdale, MN, United States
| | - Alicia Ronk
- Department of Pharmacy Services, North Memorial Medical Center, Robbinsdale, MN, United States
| | - Patty Reicks
- Department of General and Trauma Surgery, North Memorial Medical Center, Robbinsdale, MN, United States
| | - Barb Curran
- Department of General and Trauma Surgery, North Memorial Medical Center, Robbinsdale, MN, United States
| | - Krishna Rangarajan
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Harrison Tam
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Greg J Beilman
- Division of Critical Care and Acute Care Surgery, Department of Surgery, School of Medicine, University of Minnesota, Minneapolis, MN, United States; Department of General and Trauma Surgery, North Memorial Medical Center, Robbinsdale, MN, United States
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11
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Alnemari AM, Krafcik BM, Mansour TR, Gaudin D. A Comparison of Pharmacologic Therapeutic Agents Used for the Reduction of Intracranial Pressure After Traumatic Brain Injury. World Neurosurg 2017; 106:509-528. [PMID: 28712906 DOI: 10.1016/j.wneu.2017.07.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 07/01/2017] [Accepted: 07/05/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVE In neurotrauma care, a better understanding of treatments after traumatic brain injury (TBI) has led to a significant decrease in morbidity and mortality in this population. TBI represents a significant medical problem, and complications after TBI are associated with the initial injury and postevent intracranial processes such as increased intracranial pressure and brain edema. Consequently, appropriate therapeutic interventions are required to reduce brain tissue damage and improve cerebral perfusion. We present a contemporary review of literature on the use of pharmacologic therapies to reduce intracranial pressure after TBI and a comparison of their efficacy. METHODS This review was conducted by PubMed query. Only studies discussing pharmacologic management of patients after TBI were included. This review includes prospective and retrospective studies and includes randomized controlled trials as well as cohort, case-control, observational, and database studies. Systematic literature reviews, meta-analyses, and studies that considered conditions other than TBI or pediatric populations were not included. RESULTS Review of the literature describing the current pharmacologic treatment for intracranial hypertension after TBI most often discussed the use of hyperosmolar agents such as hypertonic saline and mannitol, sedatives such as fentanyl and propofol, benzodiazepines, and barbiturates. Hypertonic saline is associated with faster resolution of intracranial hypertension and restoration of optimal cerebral hemodynamics, although these advantages did not translate into long-term benefits in morbidity or mortality. In patients refractory to treatment with hyperosmolar therapy, induction of a barbiturate coma can reduce intracranial pressure, although requires close monitoring to prevent adverse events. CONCLUSIONS Current research suggests that the use of hypertonic saline after TBI is the best option for immediate decrease in intracranial pressure. A better understanding of the efficacy of each treatment option can help to direct treatment algorithms during the critical early hours of trauma care and continue to improve morbidity and mortality after TBI.
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Affiliation(s)
- Ahmed M Alnemari
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Brianna M Krafcik
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Tarek R Mansour
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Daniel Gaudin
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA.
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Dekmak A, Mantash S, Shaito A, Toutonji A, Ramadan N, Ghazale H, Kassem N, Darwish H, Zibara K. Stem cells and combination therapy for the treatment of traumatic brain injury. Behav Brain Res 2016; 340:49-62. [PMID: 28043902 DOI: 10.1016/j.bbr.2016.12.039] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 10/30/2016] [Accepted: 12/29/2016] [Indexed: 12/15/2022]
Abstract
TBI is a nondegenerative, noncongenital insult to the brain from an external mechanical force; for instance a violent blow in a car accident. It is a complex injury with a broad spectrum of symptoms and has become a major cause of death and disability in addition to being a burden on public health and societies worldwide. As such, finding a therapy for TBI has become a major health concern for many countries, which has led to the emergence of many monotherapies that have shown promising effects in animal models of TBI, but have not yet proven any significant efficacy in clinical trials. In this paper, we will review existing and novel TBI treatment options. We will first shed light on the complex pathophysiology and molecular mechanisms of this disorder, understanding of which is a necessity for launching any treatment option. We will then review most of the currently available treatments for TBI including the recent approaches in the field of stem cell therapy as an optimal solution to treat TBI. Therapy using endogenous stem cells will be reviewed, followed by therapies utilizing exogenous stem cells from embryonic, induced pluripotent, mesenchymal, and neural origin. Combination therapy is also discussed as an emergent novel approach to treat TBI. Two approaches are highlighted, an approach concerning growth factors and another using ROCK inhibitors. These approaches are highlighted with regard to their benefits in minimizing the outcomes of TBI. Finally, we focus on the consequent improvements in motor and cognitive functions after stem cell therapy. Overall, this review will cover existing treatment options and recent advancements in TBI therapy, with a focus on the potential application of these strategies as a solution to improve the functional outcomes of TBI.
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Affiliation(s)
- AmiraSan Dekmak
- ER045, Laboratory of Stem Cells, Faculty of Sciences, DSST, PRASE, Lebanese University, Beirut, Lebanon
| | - Sarah Mantash
- ER045, Laboratory of Stem Cells, Faculty of Sciences, DSST, PRASE, Lebanese University, Beirut, Lebanon; Department of Biochemistry and Molecular Genetics, American University of Beirut, Beirut, Lebanon
| | - Abdullah Shaito
- Department of Biological and Chemical Sciences, Lebanese International University, Beirut, Lebanon
| | - Amer Toutonji
- Department of Biochemistry and Molecular Genetics, American University of Beirut, Beirut, Lebanon
| | - Naify Ramadan
- ER045, Laboratory of Stem Cells, Faculty of Sciences, DSST, PRASE, Lebanese University, Beirut, Lebanon; Department of Biochemistry and Molecular Genetics, American University of Beirut, Beirut, Lebanon
| | - Hussein Ghazale
- Department of Biochemistry and Molecular Genetics, American University of Beirut, Beirut, Lebanon
| | - Nouhad Kassem
- ER045, Laboratory of Stem Cells, Faculty of Sciences, DSST, PRASE, Lebanese University, Beirut, Lebanon
| | - Hala Darwish
- Faculty of Medicine, Hariri School of Nursing, American University of Beirut, Beirut, Lebanon
| | - Kazem Zibara
- ER045, Laboratory of Stem Cells, Faculty of Sciences, DSST, PRASE, Lebanese University, Beirut, Lebanon; Laboratory of Cardiovascular Diseases and Stem Cells, Biology Department, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon.
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Abstract
Hypertonic saline (HTS) is used as an adjunct in the conservative management of increased intracranial pressure; however, the ideal concentration or route of delivery is unknown. Our objective was to assess whether there is a difference in route of delivery, bolus versus infusion, of 2% versus 3% HTS in patients with traumatic brain injury. The study comprises a retrospective analysis of all patients who sustained traumatic brain injury resulting in increased intracranial pressure that required HTS from January 2012 to December 2014. We examined time to therapeutic serum sodium concentration greater or equal to 150 mEq; incidence of ventriculostomy placement and neurosurgical intervention for refractory intracanial hypertension; and disability burden among the different infusates and route of delivery. A total of 169 patients received either 2% or 3% HTS, given as a bolus or continuous infusion. Patients had an average age of 61.4 years; 100 patients (59.2%) were male and 69 (40.8%) were female; 62 patients were taking either an antiplatelet or anticoagulant agent. Infusion of 3% saline was associated with the shortest interval to reaching a therapeutic level at 1.61 days (P = 0.024). There was no statistically significant difference between placement of a ventriculostomy among the bolus and infusion groups of 3% normal saline (NS) (P = 0.475). However, neurosurgical intervention was less prevalent in those receiving 3% infusion (P = 0.013). Infusion of 3% HTS was associated with a more rapid increase in serum sodium to therapeutic levels. Neurosurgical intervention for refractory hypertension was less prevalent in the 3% NS infusion group.
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Adamik KN, Butty E, Howard J. In vitro effects of 3% hypertonic saline and 20% mannitol on canine whole blood coagulation and platelet function. BMC Vet Res 2015; 11:242. [PMID: 26403081 PMCID: PMC4582639 DOI: 10.1186/s12917-015-0555-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 09/17/2015] [Indexed: 12/11/2022] Open
Abstract
Background Hyperosmolar therapy, using either mannitol or hypertonic saline (HTS), is considered the treatment of choice for intracranial hypertension. However, hyperosmolar agents may impair coagulation and platelet function, limiting their use in patients at risk for hemorrhage. Despite this, studies evaluating the effects of mannitol compared to other hyperosmolar agents in dogs are largely lacking. The aim of this study was to compare the in vitro effects on global hemostasis and platelet function of 20 % mannitol and 3 % HTS on canine blood. Methods Citrated whole blood from 15 healthy dogs was diluted with 0.9 % saline, 20 % mannitol and 3 % HTS in ratios of 1:16 and 1:8. Rotational thromboelastometry (ROTEM) was used to assess clotting time (CT), clot formation time (CFT) and maximal clot firmness (MCF) following extrinsic activation (Ex-tem) and after platelet inhibition (Fib-tem). A platelet function analyzer (PFA-100) was used to assess closure time (CtPFA). Results No significant differences were observed between untreated whole blood and samples diluted with saline. Samples diluted with both mannitol and HTS were hypocoagulable compared to untreated whole blood samples. At a dilution of 1:16, no significant differences were found between any measured parameter in samples diluted with saline compared to mannitol or HTS. At a 1:8 dilution, CtPFA was prolonged in samples diluted with mannitol and HTS compared to saline, and CtPFA was prolonged more with mannitol than HTS. Ex-tem CT was increased at a 1:8 dilution with mannitol compared to HTS. Ex-tem CFT was prolonged at a 1:8 dilution with both agents compared to saline, and was prolonged more with mannitol than HTS. Ex-tem MCF was reduced at a 1:8 dilution with both agents compared to saline. Discussion and Conclusions Data in this study indicate that both mannitol and HTS affect canine platelet function and whole blood coagulation in vitro in a dose-dependent fashion. The most pronounced effects were observed after high dilutions with mannitol, which impaired platelet aggregation, clot formation time, clot strength, and fibrin formation significantly more than HTS. Further in vivo studies are necessary before recommendations can be made.
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Affiliation(s)
- Katja-Nicole Adamik
- Division of Emergency and Critical Care, Small Animal Clinic, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Laenggassstrasse 128, 3012, Bern, Switzerland.
| | - Emmanuelle Butty
- Division of Emergency and Critical Care, Small Animal Clinic, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Laenggassstrasse 128, 3012, Bern, Switzerland.
| | - Judith Howard
- Clinical Diagnostic Laboratory, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Laenggassstrasse 124, 3012, Bern, Switzerland.
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Mangat HS, Härtl R. Hypertonic saline for the management of raised intracranial pressure after severe traumatic brain injury. Ann N Y Acad Sci 2015; 1345:83-8. [PMID: 25726965 DOI: 10.1111/nyas.12704] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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.
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Affiliation(s)
- Halinder S Mangat
- Division of Stroke and Critical Care, Department of Neurology, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - Roger Härtl
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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Mangat HS, Chiu YL, Gerber LM, Alimi M, Ghajar J, Härtl R. Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury. J Neurosurg 2015; 122:202-10. [DOI: 10.3171/2014.10.jns132545] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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 chi-square 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.
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Affiliation(s)
- Halinder S. Mangat
- Departments of 1Neurology and
- 2Neurological Surgery, Weill Cornell Brain and Spine Center, and
- 5NewYork-Presbyterian Hospital; and
| | | | - Linda M. Gerber
- Departments of 3Public Health and
- 4Medicine, Weill Cornell Medical College
| | - Marjan Alimi
- 2Neurological Surgery, Weill Cornell Brain and Spine Center, and
- 5NewYork-Presbyterian Hospital; and
| | - Jamshid Ghajar
- 2Neurological Surgery, Weill Cornell Brain and Spine Center, and
- 6The Brain Trauma Foundation, New York, New York
| | - Roger Härtl
- 2Neurological Surgery, Weill Cornell Brain and Spine Center, and
- 5NewYork-Presbyterian Hospital; and
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Colton K, Yang S, Hu PF, Chen HH, Stansbury LG, Scalea TM, Stein DM. Responsiveness to therapy for increased intracranial pressure in traumatic brain injury is associated with neurological outcome. Injury 2014; 45:2084-8. [PMID: 25304159 DOI: 10.1016/j.injury.2014.08.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 07/26/2014] [Accepted: 08/28/2014] [Indexed: 02/02/2023]
Abstract
In patients with severe traumatic brain injury, increased intracranial pressure (ICP) is associated with poor functional outcome or death. Hypertonic saline (HTS) is a hyperosmolar therapy commonly used to treat increased ICP; this study aimed to measure initial patient response to HTS and look for association with patient outcome. Patients >17 years old, admitted and requiring ICP monitoring between 2008 and 2010 at a large urban tertiary care facility were retrospectively enrolled. The first dose of hypertonic saline administered after admission for ICP >19mmHg was recorded and correlated with vital signs recorded at the bedside. The absolute and relative change in ICP at 1 and 2h after HTS administration was calculated. Patients were stratified by mortality and long-term (≥6 months) functional neurological outcome. We identified 46 patients who received at least 1 dose of HTS for ICP>19, of whom 80% were male, mean age 34.4, with a median post-resuscitation GCS score of 6. All patients showed a significant decrease in ICP 1h after HTS administration. Two hours post-administration, survivors showed a further decrease in ICP (43% reduction from baseline), while ICP began to rebound in non-survivors (17% reduction from baseline). When patients were stratified for long-term neurological outcome, results were similar, with a significant difference in groups by 2h after HTS administration. In patients treated with HTS for intracranial hypertension, those who survived or had good neurological outcome, when compared to those who died or had poor outcomes, showed a significantly larger sustained decrease in ICP 2h after administration. This suggests that even early in a patient's treatment, treatment responsiveness is associated with mortality or poor functional outcome. While this work is preliminary, it suggests that early failure to obtain a sustainable response to hyperosmolar therapy may warrant greater treatment intensity or therapy escalation.
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Affiliation(s)
- K Colton
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA; Duke University School of Medicine, Durham, NC, USA.
| | - S Yang
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - P F Hu
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - H H Chen
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - L G Stansbury
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - T M Scalea
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - D M Stein
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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Colton K, Yang S, Hu PF, Chen HH, Bonds B, Stansbury LG, Scalea TM, Stein DM. Pharmacologic Treatment Reduces Pressure Times Time Dose and Relative Duration of Intracranial Hypertension. J Intensive Care Med 2014; 31:263-9. [PMID: 25320157 DOI: 10.1177/0885066614555692] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 09/18/2014] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Past work has shown the importance of the "pressure times time dose" (PTD) of intracranial hypertension (intracranial pressure [ICP] > 19 mm Hg) in predicting outcome after severe traumatic brain injury. We used automated data collection to measure the effect of common medications on the duration and dose of intracranial hypertension. METHODS Patients >17 years old, admitted and requiring ICP monitoring between 2008 and 2010 at a single, large urban tertiary care facility, were retrospectively enrolled. Timing and dose of ICP-directed therapy were recorded from paper and electronic medical records. The ICP data were collected automatically at 6-second intervals and averaged over 5 minutes. The percentage of time of intracranial hypertension (PTI) and PTD (mm Hg h) were calculated. RESULTS A total of 98 patients with 664 treatment instances were identified. Baseline PTD ranged from 27 (before administration of propofol and fentanyl) to 150 mm Hg h (before mannitol). A "small" dose of hypertonic saline (HTS; ≤250 mL 3%) reduced PTD by 38% in the first hour and 37% in the second hour and reduced the time with ICP >19 by 38% and 39% after 1 and 2 hours, respectively. A "large" dose of HTS reduced PTD by 40% in the first hour and 63% in the second (PTI reduction of 36% and 50%, respectively). An increased dose of propofol or fentanyl infusion failed to decrease PTD but reduced PTI between 14% (propofol alone) and 30% (combined increase in propofol and fentanyl, after 2 hours). Barbiturates failed to decrease PTD but decreased PTI by 30% up to 2 hours after administration. All reductions reported are significantly changed from baseline, P < .05. CONCLUSION Baseline PTD values before drug administration reflects varied patient criticality, with much higher values seen before the use of mannitol or barbiturates. Treatment with HTS reduced PTD and PTI burden significantly more than escalation of sedation or pain management, and this effect remained significant at 2 hours after administration.
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Affiliation(s)
- Katharine Colton
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA Duke University School of Medicine, Durham, NC, USA
| | - S Yang
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - P F Hu
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - H H Chen
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - B Bonds
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - L G Stansbury
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - T M Scalea
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - D M Stein
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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Kashefi P, Montazeri K, Hashemi ST. Effect of hypertonic saline on hypotension following induction of general anesthesia: A randomized controlled trial. Adv Biomed Res 2014; 3:183. [PMID: 25250297 PMCID: PMC4166055 DOI: 10.4103/2277-9175.140088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Accepted: 06/18/2014] [Indexed: 11/19/2022] Open
Abstract
Background: The aim of this study was to examine the effects of preoperatively administered i.v. hypertonic saline on hypotension following induction of general anesthesia. Materials and Methods: Fifty-four patients who scheduled for elective surgery were randomly allocated to two groups of 27 patients who received hypertonic saline 5% (2.3 ml/kg) or received normal saline (13 ml/kg). Infusion of hypertonic saline was done half an hour before induction of anesthesia during 30 minutes. Anesthesia was conducted in a standard protocol for all patients. Age, sex, body mass index (BMI), systolic and diastolic blood pressure (SBP, DBP), heart rate (HR) and mean arterial pressure (MAP) were assessed in all patients. Results: The mean age of patients was 36.68 ± 10.8 years. Forty percent of patients were male. The mean SBP at min 2 and min 5, mean of DBP at min 2, 5, and 15, mean of HR at all time points and mean of MAP at min 2 and 15 between groups were no significantly different (P > 0.05), but mean of SBP at min 10 and 15, mean of DBP at min 10, and mean of MAP at min 5 and 10 in hypertonic saline group was significantly more than the normal group (P < 0.05). Trend of SBP, DBP, HR and MAP between groups were not significantly different (P > 0.05). Conclusions: Infusion of hypertonic saline 5% (2.3 mg/kg) before the general anesthesia led to a useful reduction in MAP and reduced heart rate, with no episodes of severe hypotension.
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Affiliation(s)
- Parviz Kashefi
- Department of Anesthesia, Medical School, St-Alzahra Medical Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Kamran Montazeri
- Department of Anesthesia, Medical School, St-Alzahra Medical Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Seyed Taghi Hashemi
- Department of Anesthesia, Medical School, St-Alzahra Medical Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Prehospital hypertonic saline resuscitation attenuates the activation and promotes apoptosis of neutrophils in patients with severe traumatic brain injury. Shock 2014; 40:366-74. [PMID: 24088993 DOI: 10.1097/shk.0000000000000038] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Activation of polymorphonuclear neutrophils (PMNs) is thought to contribute to traumatic brain injury (TBI). Since hypertonic fluids can inhibit PMN activation, we studied whether hypertonic fluid resuscitation can reduce excessive PMN activation in TBI patients. METHODS Trauma patients with severe TBI were resuscitated with 250 mL of either 7.5% hypertonic saline (HS; n = 22), HS + 6% dextran-70 (HSD; n = 22), or 0.9% normal saline (NS; n = 39), and blood samples were collected on hospital admission and 12 and 24 h after resuscitation. Polymorphonuclear neutrophil activation (CD11b, CD62L, CD64) and degranulation (CD63, CD66b, CD35) markers and oxidative-burst activity, as well as spontaneous PMN apoptosis were measured by flow cytometry. RESULTS Relative to healthy controls, TBI patients showed increased PMN activation and decreased apoptosis of PMNs. In the HS group, but not in the HSD group, markers of PMN adhesion (CD11b, CD64) and degranulation (CD35, CD66b) were significantly lower than those in the NS group. These effects were particularly pronounced 12 h after resuscitation. Treatment with HS and HSD inhibited PMN oxidative burst responses compared with NS-treated patients. Hypertonic saline alone partially restored delayed PMN apoptosis. Despite these differences, the groups did not differ in clinical outcome parameters such as mortality and Extended Glasgow Outcome Scale. CONCLUSIONS This study demonstrates that prehospital resuscitation with HS can partially restore normal PMN activity and the apoptotic behavior of PMNs, whereas resuscitation with HSD was largely ineffective. Although the results are intriguing, additional research will be required to translate these effects of HS into treatment strategies that improve clinical outcome in TBI patients.
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Algattas H, Huang JH. Traumatic Brain Injury pathophysiology and treatments: early, intermediate, and late phases post-injury. Int J Mol Sci 2013; 15:309-41. [PMID: 24381049 PMCID: PMC3907812 DOI: 10.3390/ijms15010309] [Citation(s) in RCA: 158] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 12/02/2013] [Accepted: 12/20/2013] [Indexed: 12/25/2022] Open
Abstract
Traumatic Brain Injury (TBI) affects a large proportion and extensive array of individuals in the population. While precise pathological mechanisms are lacking, the growing base of knowledge concerning TBI has put increased emphasis on its understanding and treatment. Most treatments of TBI are aimed at ameliorating secondary insults arising from the injury; these insults can be characterized with respect to time post-injury, including early, intermediate, and late pathological changes. Early pathological responses are due to energy depletion and cell death secondary to excitotoxicity, the intermediate phase is characterized by neuroinflammation and the late stage by increased susceptibility to seizures and epilepsy. Current treatments of TBI have been tailored to these distinct pathological stages with some overlap. Many prophylactic, pharmacologic, and surgical treatments are used post-TBI to halt the progression of these pathologic reactions. In the present review, we discuss the mechanisms of the pathological hallmarks of TBI and both current and novel treatments which target the respective pathways.
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Affiliation(s)
- Hanna Algattas
- School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 441, Rochester, NY 14642, USA.
| | - Jason H Huang
- School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 441, Rochester, NY 14642, USA.
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Li YH, Yu CH, Chien TJ, Huang RC, Tan PH, Cheng YS, Chen CA, Hueng DY. Hypertonic saline. J Neurosurg 2013; 119:1646. [PMID: 24053498 DOI: 10.3171/2013.6.jns131094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Yu-Huei Li
- Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Lewandowski-Belfer JJ, Patel AV, Darracott RM, Jackson DA, Nordeen JD, Freeman WD. Safety and Efficacy of Repeated Doses of 14.6 or 23.4 % Hypertonic Saline for Refractory Intracranial Hypertension. Neurocrit Care 2013; 20:436-42. [DOI: 10.1007/s12028-013-9907-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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