title: Osmolar therapy in pediatric traumatic brain injury.
abstract: OBJECTIVE
  To describe patterns of use for mannitol and hypertonic saline in children with traumatic brain injury, to evaluate any potential associations between hypertonic saline and mannitol use and patient demographic, injury, and treatment hospital characteristics, and to determine whether the 2003 guidelines for severe pediatric traumatic brain injury impacted clinical practice regarding osmolar therapy.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Pediatric Health Information System database, January, 2001 to December, 2008.
  
  
  METHODS
  Children (age <18 yrs) with traumatic brain injury and head/neck Abbreviated Injury Scale score ≥ 3 who received mechanical ventilation and intensive care.
  
  
  METHODS
  : None.
  
  
  RESULTS
  The primary outcome was hospital billing for parenteral hypertonic saline and mannitol use, by day of service. Overall, 33% (2,069 of 6,238) of the patients received hypertonic saline, and 40% (2,500 of 6,238) received mannitol. Of the 1,854 patients who received hypertonic saline or mannitol for ≥ 2 days in the first week of therapy, 29% did not have intracranial pressure monitoring. After adjustment for hospital-level variation, primary insurance payer, and overall injury severity, use of both drugs was independently associated with older patient age, intracranial hemorrhage (other than epidural), skull fracture, and higher head/neck injury severity. Hypertonic saline use increased and mannitol use decreased with publication of the 2003 guidelines, and these trends continued through 2008.
  
  
  CONCLUSIONS
  Hypertonic saline and mannitol are used less in infants than in older children. The patient-level and hospital-level variation in osmolar therapy use and the substantial amount of sustained osmolar therapy without intracranial pressure monitoring suggest opportunities to improve the quality of pediatric traumatic brain injury care. With limited high-quality evidence available, published expert guidelines appear to significantly impact clinical practice in this area.
authors.affiliation: University of Utah School of Medicine, Salt Lake City, UT, USA. tell.bennett@hsc.utah.edu
authors.forename: Tellen D
authors.initials: TD
authors.lastname: Bennett
authors.forename: Kimberly D
authors.initials: KD
authors.lastname: Statler
authors.forename: E Kent
authors.initials: EK
authors.lastname: Korgenski
authors.forename: Susan L
authors.initials: SL
authors.lastname: Bratton
mesh_terms: D000293:Adolescent; D000367:Age Factors; D001930:Brain Injuries / Q000188:drug therapy / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015601:Injury Severity Score; D007427:Intracranial Pressure / Q000187:drug effects; D008297:Male; D008353:Mannitol / Q000008:administration & dosage / Q000627:therapeutic use*; D012189:Retrospective Studies; D012462:Saline Solution, Hypertonic / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D012462:Saline Solution, Hypertonic; D008353:Mannitol