title: Hyperosmolar therapy in pediatric traumatic brain injury: a retrospective study.
abstract: OBJECTIVE
  The objectives of the study are to describe the use of hyperosmolar therapy in pediatric traumatic brain injury (TBI) and examine its effect on intracranial pressure (ICP) and cerebral perfusion pressure (CPP).
  
  
  METHODS
  A retrospective review of patients with severe TBI admitted to the pediatric intensive care unit (PICU) was conducted. Inclusion criteria were ICP monitoring and administration of a hyperosmolar agent (20 % mannitol or 3 % hypertonic saline) within 48 h of PICU admission; for which dose and timing were recorded. For the first two boluses received for increased ICP (>20 mmHg), the impact on ICP and CPP was assessed during the following 4 h, using repeated measures ANOVA. Co-interventions to control ICP (additional hyperosmolar agent, propofol, or barbiturate bolus) and serum sodium were also documented.
  
  
  METHODS
  A tertiary care pediatric hospital center.
  
  
  METHODS
  Children aged 1 month to 18 years, with severe traumatic brain injury (Glasgow Coma Score ≤ 8) and intracranial pressure (ICP) monitor.
  
  
  RESULTS
  Sixty-four patients were eligible, of which 16 met inclusion criteria. Average age was 11 years (SD ± 4) and median Glasgow Coma Score was 6 (range 4-7). Seventy percent of boluses were 3 % hypertonic saline, with no identified baseline difference associated with this initial choice. Both mannitol and hypertonic saline were followed by a non-significant decrease in ICP (mannitol, p = 0.055 and hypertonic saline, p = 0.096). There was no significant change in CPP post bolus. A co-intervention occurred in 69 % of patients within the 4 h post hyperosmolar agent, and eight patients received continuous 3 % saline.
  
  
  CONCLUSIONS
  In pediatric TBI with intracranial hypertension, mannitol and 3 % hypertonic saline are commonly used, but dose and therapeutic threshold for use vary without clear indications for one versus another. Controlled trials are warranted, but several barriers were identified, including high exclusion rate, multiple co-interventions, and care variability.
authors: Department of Critial Care, CHU Sainte-Justine, University de Montréal, 3175 Cote Sainte-Catherine, Montreal, Québec, H3T 1C5, Canada. nadia.roumeliotis@gmail.com.
authors: Nadia
authors: http://orcid.org/0000-0001-7463-1233
authors: N
authors: Roumeliotis
authors: Research Center of CHU Sainte-Justine, University de Montréal, Montréal, QC, Canada.
authors: Christian
authors: C
authors: Dong
authors: Department of Critial Care, CHU Sainte-Justine, University de Montréal, 3175 Cote Sainte-Catherine, Montreal, Québec, H3T 1C5, Canada.
authors: Géraldine
authors: G
authors: Pettersen
authors: Department of Neurosurgery, CHU Sainte-Justine, University de Montréal, Montréal, QC, Canada.
authors: Louis
authors: L
authors: Crevier
authors: Department of Critial Care, CHU Sainte-Justine, University de Montréal, 3175 Cote Sainte-Catherine, Montreal, Québec, H3T 1C5, Canada.
authors: Guillaume
authors: G
authors: Emeriaud
mesh_terms: D000293:Adolescent; D000070642:Brain Injuries, Traumatic / Q000188:drug therapy*; D002560:Cerebrovascular Circulation / Q000187:drug effects*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric; D019586:Intracranial Hypertension / Q000188:drug therapy*; D008297:Male; D008353:Mannitol / Q000627:therapeutic use*; D012189:Retrospective Studies; D012462:Saline Solution, Hypertonic / Q000627:therapeutic use*
chemical_list: D012462:Saline Solution, Hypertonic; D008353:Mannitol
keywords: 3 % hypertonic saline; Hyperosmolar therapy; Intracranial hypertension; Mannitol; Pediatric; Traumatic brain injury