title: A Systematic Review of Randomized Controlled Trials Comparing Hypertonic Sodium Solutions and Mannitol for Traumatic Brain Injury: Implications for Emergency Department Management.
abstract: OBJECTIVE
  To comparatively evaluate hypertonic sodium (HTS) and mannitol in patients following acute traumatic brain injury (TBI) on the outcomes of all-cause mortality, neurological disability, intracranial pressure (ICP) change from baseline, ICP treatment failure, and serious adverse events.
  
  
  METHODS
  PubMed, EMBASE, CENTRAL, Cochrane Database of Systematic Reviews, ClinicalTrials.gov, and WHO ICTRP (World Health Organization International Clinical Trials Registry Platform) were searched (inception to November 2015) using hypertonic saline solutions, sodium chloride, mannitol, osmotic diuretic, traumatic brain injury, brain injuries, and head injury. Searches were limited to humans. Clinical practice guidelines and bibliographies were reviewed.
  
  
  METHODS
  Prospective, randomized trials comparing HTS and mannitol in adults (≥16 years) with severe TBI (Glasgow Coma Scale score ≤8) and elevated ICP were included. ICP elevation, ICP reduction, and treatment failure were defined using study definitions.
  
  
  RESULTS
  Of 326 articles screened, 7 trials enrolling a total of 191 patients met inclusion criteria. Studies were underpowered to detect a significant difference in mortality or neurological outcomes. Due to significant heterogeneity and differences in reporting ICP change from baseline, this outcome was not meta-analyzed. No difference between HTS and mannitol was observed for mean ICP reduction; however, risk of ICP treatment failure favored HTS (risk ratio [RR] = 0.39; 95% CI = 0.18-0.81). Serious adverse events were not reported.
  
  
  CONCLUSIONS
  Based on limited data, clinically important differences in mortality, neurological outcomes, and ICP reduction were not observed between HTS or mannitol in the management of severe TBI. HTS appears to lead to fewer ICP treatment failures.
authors.affiliation: University of British Columbia, Vancouver, BC, Canada.
authors.forename: Sarah
authors.initials: S
authors.lastname: Burgess
authors.affiliation: University of British Columbia, Vancouver, BC, Canada VCHRI Centre for Clinical Epidemiology and Evaluation, Vancouver, BC, Canada.
authors.forename: Riyad B
authors.initials: RB
authors.lastname: Abu-Laban
authors.affiliation: University of British Columbia, Vancouver, BC, Canada Interior Health, Kelowna, BC, Canada.
authors.forename: Richard S
authors.initials: RS
authors.lastname: Slavik
authors.affiliation: University of British Columbia, Vancouver, BC, Canada British Columbia Emergency Health Services, Vancouver, BC, Canada.
authors.forename: Erik N
authors.initials: EN
authors.lastname: Vu
authors.affiliation: University of British Columbia, Vancouver, BC, Canada peter.zed@ubc.ca.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Zed
mesh_terms: D000328:Adult; D001930:Brain Injuries / Q000150:complications / Q000628:therapy*; D004234:Diuretics, Osmotic / Q000008:administration & dosage; D004636:Emergency Service, Hospital; D006801:Humans; D019586:Intracranial Hypertension / Q000628:therapy; D007427:Intracranial Pressure; D008353:Mannitol / Q000008:administration & dosage* / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D012462:Saline Solution, Hypertonic / Q000008:administration & dosage* / Q000627:therapeutic use; D017211:Treatment Failure
chemical_list: D004234:Diuretics, Osmotic; D012462:Saline Solution, Hypertonic; D008353:Mannitol
keywords: emergency medicine; hypertonic saline; intracranial pressure; mannitol; trauma; traumatic brain injury