title: Hypertonic saline for brain relaxation and intracranial pressure in patients undergoing neurosurgical procedures: a meta-analysis of randomized controlled trials.
abstract: BACKGROUND
  A wealth of evidence from randomized controlled trials (RCTs) has indicated that hypertonic saline (HS) is at least as effective as, if not better than, mannitol in the treatment of increased intracranial pressure(ICP). However, there is little known about the effects of HS in patients during neurosurgery. Thus, this meta-analysis was performed to compare the intraoperative effects of HS with mannitol in patients undergoing craniotomy.
  
  
  METHODS
  According to the research strategy, we searched PUBMED, EMBASE and Cochrane Central Register of Controlled Trials. Other sources such as the internet-based clinical trial registries and conference proceedings were also searched. After literature searching, two investigators independently performed literature screening, quality assessment of the included trials and data extraction. The outcomes included intraoperative brain relaxation, intraoperative ICP, total volume of fluid required, diuresis, hemodynamic parameters, electrolyte level, mortality or dependence and adverse events.
  
  
  RESULTS
  Seven RCTs with 468 participants were included. The quality of the included trials was acceptable. HS could significantly increase the odds of satisfactory intraoperative brain relaxation (OR: 2.25, 95% CI: 1.32-3.81; P = 0.003) and decrease the mean difference (MD) of maximal ICP (MD: -2.51 mmHg, 95% CI: -3.39--1.93 mmHg; P<0.00001) in comparison with mannitol with no significant heterogeneity among the study results. Compared with HS, mannitol had a more prominent diuretic effect. And patients treated with HS had significantly higher serum sodium than mannitol-treated patients.
  
  
  CONCLUSIONS
  Considering that robust outcome measures are absent because brain relaxation and ICP can be influenced by several factors except for the hyperosmotic agents, the results of present meta-analysis should be interpreted with cautions. Well-designed RCTs in the future are needed to further test the present results, identify the impact of HS on the clinically relevant outcomes and explore the potential mechanisms of HS.
authors: Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, P.R. China.
authors: Liujiazi
authors: L
authors: Shao
authors: Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, P.R. China.
authors: Fangxiao
authors: F
authors: Hong
authors: Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, P.R. China.
authors: Yi
authors: Y
authors: Zou
authors: Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, P.R. China.
authors: Xiaofang
authors: X
authors: Hao
authors: Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, P.R. China.
authors: Haijun
authors: H
authors: Hou
authors: Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, P.R. China.
authors: Ming
authors: M
authors: Tian
mesh_terms: D001794:Blood Pressure / Q000187:drug effects; D001921:Brain / Q000187:drug effects / Q000503:physiopathology* / Q000601:surgery*; D004234:Diuretics, Osmotic / Q000494:pharmacology; D005500:Follow-Up Studies; D006439:Hemodynamics / Q000187:drug effects; D006801:Humans; D007427:Intracranial Pressure / Q000187:drug effects*; D008353:Mannitol / Q000494:pharmacology; D019635:Neurosurgical Procedures / Q000009:adverse effects / Q000401:mortality; D009994:Osmolar Concentration; D017594:Publication Bias; D016032:Randomized Controlled Trials as Topic; D012462:Saline Solution, Hypertonic / Q000494:pharmacology*; D012964:Sodium / Q000097:blood
chemical_list: D004234:Diuretics, Osmotic; D012462:Saline Solution, Hypertonic; D008353:Mannitol; D012964:Sodium
references: Surgery. 2001 May;129(5):567-75
references: 11331449
references: Minerva Anestesiol. 2001 Sep;67(9):603-11
references: 11731749
references: Anesthesiology. 2003 Feb;98(2):329-36
references: 12552189
references: Stroke. 2003 Jun;34(6):1389-96
references: 12730557
references: J Neurosurg. 2004 Oct;101(4):621-6
references: 15481716
references: J Neurosurg Anesthesiol. 1996 Apr;8(2):126-32
references: 8829559
references: J Neurosurg Anesthesiol. 1997 Oct;9(4):329-34
references: 9339405
references: Neurosurgery. 2005 Aug;57(2):207-15; discussion 207-15
references: 16094147
references: Ann Surg. 2006 Jan;243(1):47-57
references: 16371736
references: Shock. 2006 Apr;25(4):321-8
references: 16670632
references: Br J Anaesth. 2007 Jul;99(1):68-74
references: 17573395
references: Neurosurg Rev. 2007 Oct;30(4):277-89; discussion 289-90
references: 17574484
references: Curr Opin Anaesthesiol. 2007 Oct;20(5):414-26
references: 17873594
references: Anesthesiology. 2007 Nov;107(5):697-704
references: 18073543
references: Acta Neurochir (Wien). 2008 Apr;150(4):337-44; discussion 344
references: 18297231
references: Neurocrit Care. 2008;9(2):204-9
references: 18563637
references: Clinics (Sao Paulo). 2008 Dec;63(6):833-40
references: 19061009
references: J Neurosci Nurs. 2008 Dec;40(6):362-8
references: 19170304
references: J Neurosurg Anesthesiol. 2009 Jul;21(3):248-52
references: 19543004
references: Anaesthesia. 2009 Sep;64(9):990-1003
references: 19686485
references: Cochrane Database Syst Rev. 2010;(1):CD005576
references: 20091580
references: Anesth Analg. 2010 Mar 1;110(3):903-7
references: 20185666
references: Ann Surg. 2011 Mar;253(3):431-41
references: 21178763
references: Crit Care Med. 2011 Mar;39(3):554-9
references: 21242790
references: Clinics (Sao Paulo). 2013;68(3):323-8
references: 23644851
references: J Surg Res. 2014 Oct;191(2):448-54
references: 24836422