title: New trends in hyperosmolar therapy?
abstract: OBJECTIVE
  To discuss trends in the use of osmotic therapy.
  
  
  RESULTS
  Use of osmotic therapy has evolved from bolus administration of mannitol to routine use of hypertonic saline as a bolus as well as in continuous infusions to creating a sustained hyperosmolar state.In a survey of neurointensivists 55% favored hypertonic saline over mannitol. Retrospective studies suggest better intracranial pressure (ICP) control with hypertonic saline. Whereas a prospective study in adults with head injury compared alternating doses of mannitol and hypertonic saline and found no difference in change in ICP control or outcome, two meta-analyses, which did not include this study, favored hypertonic saline for ICP control (although the absolute difference of 2 mmHg is of little clinical value) with no difference in outcome.Hypertonic saline has also been administered by infusions to creating a sustained stable hyperosmolar state. Two studies, using historical controls, suggested benefit of hypertonic saline infusions. In a prospective, randomized study, in children with severe head injury Lactated Ringer's solution was compared to hypertonic saline. Although ICP control was similar, the hypertonic saline group required fewer other interventions.
  
  
  CONCLUSIONS
  The existing data do not support favoring boluses of hypertonic saline over mannitol in terms of ICP control, let alone outcome. The rationale for continuous infusions to create a sustained hyperosmolar state is open to discussion and use of this approach should be curtailed pending further research.
authors: Neurocritical Care Section, Department of Neurology, Washington University School of Medicine, Saint Louis, MO 63110, USA. diringerm@wustl.edu
authors: Michael N
authors: MN
authors: Diringer
mesh_terms: D002545:Brain Ischemia / Q000188:drug therapy* / Q000503:physiopathology; D002543:Cerebral Hemorrhage / Q000188:drug therapy* / Q000503:physiopathology; D006259:Craniocerebral Trauma / Q000188:drug therapy* / Q000503:physiopathology; D003422:Critical Care / Q000379:methods / Q000639:trends*; D004234:Diuretics, Osmotic / Q000494:pharmacology / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D019586:Intracranial Hypertension / Q000188:drug therapy* / Q000503:physiopathology; D008297:Male; D008353:Mannitol / Q000494:pharmacology / Q000627:therapeutic use*; D009994:Osmolar Concentration; D017410:Practice Guidelines as Topic; D012462:Saline Solution, Hypertonic / Q000494:pharmacology / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D004234:Diuretics, Osmotic; D012462:Saline Solution, Hypertonic; D008353:Mannitol
references: Neurocrit Care. 2008;9(2):204-9
references: 18563637
references: Cerebrovasc Dis. 2011;31(6):521-31
references: 21487216
references: J Clin Anesth. 2012 Jun;24(4):318-23
references: 22608588
references: J Neurosurg Anesthesiol. 2012 Oct;24(4):407-12
references: 22955195
references: J Lab Clin Med. 1991 Jan;117(1):60-6
references: 1987310
references: Exp Neurol. 1982 Sep;77(3):599-611
references: 6811305
references: Crit Care Med. 2011 Jul;39(7):1766-72
references: 21494103
references: Annu Rev Med. 1993;44:289-301
references: 8476251
references: Stroke. 2011 Jun;42(6):1540-5
references: 21512173
references: Crit Care Med. 2012 Jan;40(1):208-15
references: 21926592
references: Pediatr Emerg Care. 2011 Dec;27(12):1113-7
references: 22134236
references: J Neurosurg. 1962 Dec;19:1038-43
references: 14001309
references: Ann Surg. 1935 Jan;101(1):76-132
references: 17856499
references: Circulation. 1994 Sep;90(3):1588-601
references: 8087974
references: Crit Care. 2012 Feb 20;16(1):113
references: 22353146
references: J Neurotrauma. 2007;24 Suppl 1:S14-20
references: 17511539
references: J Neurosurg. 2011 Feb;114(2):543; discussion 544
references: 21087201
references: J Neurosurg. 2011 Feb;114(2):545-8
references: 21087203
references: J Neurosurg. 1988 Mar;68(3):478-81
references: 3343621
references: J Neurosurg. 2012 Jan;116(1):210-21
references: 21942722
references: J Neurosurg. 1981 Oct;55(4):550-3
references: 6792325
references: Neurochem Int. 2010 Nov;57(4):468-88
references: 20380861
references: Stroke. 2010 Sep;41(9):2108-29
references: 20651276
references: J Neurosurg. 1962 Oct;19:897-901
references: 13977131
references: Am J Physiol. 1986 Sep;251(3 Pt 2):F485-9
references: 3752258
references: Crit Care Med. 2009 Apr;37(4):1433-41
references: 19242317
references: N Engl J Med. 1995 Nov 9;333(19):1260-6
references: 7566004
references: J Neurosurg. 2012 Jan;116(1):256-7; author reply 257
references: 22035273
references: N Engl J Med. 2000 May 18;342(20):1493-9
references: 10816188
references: Crit Care Med. 2011 Mar;39(3):554-9
references: 21242790
references: J Neurosurg. 1986 Apr;64(4):627-32
references: 3950745
references: Neurocrit Care. 2011 Apr;14(2):222-8
references: 21153930
references: Acad Emerg Med. 1997 Jul;4(7):662-73
references: 9223688
references: J Neurosurg Anesthesiol. 2012 Oct;24(4):402-6
references: 22955194
references: Crit Care. 2011;15(5):R260
references: 22035596
references: Neurosurgery. 1980 Mar;6(3):237-42
references: 7383286
references: Crit Care Med. 1998 Jul;26(7):1265-70
references: 9671379