title: The use of 23.4% hypertonic saline for the management of elevated intracranial pressure in patients with severe traumatic brain injury: a pilot study.
abstract: BACKGROUND
  Oncotic agents are a therapeutic mainstay for the management of intracranial hypertension. Both mannitol and varied concentrations of hypertonic saline (HTS) have been shown to be effective at reducing elevated intracranial pressure (ICP). We compared the safety and efficacy of 23.4% HTS to mannitol for acute management of elevated ICP after traumatic brain injury (TBI).
  
  
  METHODS
  After approval from our institutional review board, the records of patients admitted with severe TBI who received mannitol or HTS were reviewed. Demographic and physiologic data were recorded. ICP, cerebral perfusion pressure, reduction of ICP after dose administration, serum sodium, osmolality, and magnitude of dose response during the subsequent 60 minutes were analyzed. Efficacy was determined by comparison of proportion of patients with any response and mean change in ICP after dosing with either agent. Safety was determined by recording any new postinfusion electrolyte or neurologic anomalies. Data were compared using chi2 test, accepting p < 0.05 as significant.
  
  
  RESULTS
  Twenty-two patients with severe TBI received 210 doses of either mannitol or HTS. All patients suffered severe blunt injury (mean Injury Severity Score 28 +/- 11). HTS patients had a significantly higher ICP at the initiation of therapy than that of mannitol group (30.7 +/- 7.94 mm Hg vs. 28.3 +/- 8.07 mm Hg, respectively). There was no difference in initial cerebral perfusion pressure. Mean ICP reduction in the hour after administration of 102 doses of mannitol and 108 doses of HTS was greater for patients receiving HTS (9.3 +/- 7.37 mm Hg vs. 6.4 +/- 6.57 mm Hg, respectively; p = 0.0028, chi2). More patients responded to HTS (92.6% HTS vs. 74% mannitol; p = 0.0002, chi2). There was no significant difference between groups in the duration of ICP reduction after dose administration (4.1 hours vs. 3.8 hours, respectively). No adverse events after administration of either agent were identified.
  
  
  CONCLUSIONS
  Based on this retrospective analysis, 23.4% HTS is more efficacious than mannitol in reducing ICP. If these results are confirmed in a prospective, randomized study, 23.4% HTS may become the agent of choice for the management of elevated ICP after TBI.
authors: Department of Surgery, University of Florida Health Science Center, Jacksonville, Florida 32209, USA. andy.kerwin@jax.ufl.edu
authors: Andrew J
authors: AJ
authors: Kerwin
authors: Miren A
authors: MA
authors: Schinco
authors: Joseph J
authors: JJ
authors: Tepas
authors: William H
authors: WH
authors: Renfro
authors: Elizabeth A
authors: EA
authors: Vitarbo
authors: Michael
authors: M
authors: Muehlberger
mesh_terms: D000328:Adult; D001930:Brain Injuries / Q000150:complications*; D004234:Diuretics, Osmotic / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D019586:Intracranial Hypertension / Q000188:drug therapy* / Q000209:etiology*; D008297:Male; D008353:Mannitol / Q000627:therapeutic use; D008875:Middle Aged; D010865:Pilot Projects; D012189:Retrospective Studies; D012462:Saline Solution, Hypertonic / Q000627:therapeutic use*; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D004234:Diuretics, Osmotic; D012462:Saline Solution, Hypertonic; D008353:Mannitol