Association between continuous hyperosmolar therapy and survival in patients with traumatic brain injury – a multicentre prospective cohort study and systematic review

Asehnoune, Karim; Lasocki, Sigismond; Séguin, Philippe; Geeraerts, Thomas; Perrigault, Pierre François; Dahyot‐Fizelier, Claire; Paugam–Burtz, Catherine; Cook, Fabrice; Latte, Dominique Demeure Dit; Cinotti, Raphaël; Mahé, Pierre; Fortuit, Camille; Pirracchio, Romain; Feuillet, Fanny; Sébille, Véronique; Roquilly, Antoine

doi:10.1186/s13054-017-1918-4

Cited by 49 publications

(30 citation statements)

References 39 publications

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“…However, a direct comparison between the few head-to-head studies carried out is challenged by the varying treatment strategies; (i) continuous or bolus injections, (ii) different doses/volumes of the osmotic agent, and (iii) different time windows, which altogether resulted in variable plasma osmolarities. In addition, diverse patient populations and outcome measurements [ 39 ] further hamper the comparison between clinical trials. It is, therefore, still questionable which osmotic agent is superior [ 1 , 40 ] and animal/clinical studies, which allow direct comparison, are warranted.…”

Section: Discussionmentioning

confidence: 99%

Cerebral influx of Na+ and Cl− as the osmotherapy-mediated rebound response in rats

Oernbo

Lykke

Steffensen

et al. 2018

Fluids Barriers CNS

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BackgroundCerebral edema can cause life-threatening increase in intracranial pressure. Besides surgical craniectomy performed in severe cases, osmotherapy may be employed to lower the intracranial pressure by osmotic extraction of cerebral fluid upon intravenous infusion of mannitol or NaCl. A so-called rebound effect can, however, hinder continuous reduction in cerebral fluid by yet unresolved mechanisms.MethodsWe determined the brain water and electrolyte content in healthy rats treated with osmotherapy. Osmotherapy (elevated plasma osmolarity) was mediated by intraperitoneal injection of NaCl or mannitol with inclusion of pharmacological inhibitors of selected ion-transporters present at the capillary lumen or choroidal membranes. Brain barrier integrity was determined by fluorescence detection following intravenous delivery of Na+-fluorescein.ResultsNaCl was slightly more efficient than mannitol as an osmotic agent. The brain water loss was only ~ 60% of that predicted from ideal osmotic behavior, which could be accounted for by cerebral Na+ and Cl− accumulation. This electrolyte accumulation represented the majority of the rebound response, which was unaffected by the employed pharmacological agents. The brain barriers remained intact during the elevated plasma osmolarity.ConclusionsA brain volume regulatory response occurs during osmotherapy, leading to the rebound response. This response involves brain accumulation of Na+ and Cl− and takes place by unresolved molecular mechanisms that do not include the common ion-transporting mechanisms located in the capillary endothelium at the blood–brain barrier and in the choroid plexus epithelium at the blood–CSF barrier. Future identification of these ion-transporting routes could provide a pharmacological target to prevent the rebound effect associated with the widely used osmotherapy.

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Section: Discussionmentioning

confidence: 99%

Cerebral influx of Na+ and Cl− as the osmotherapy-mediated rebound response in rats

Oernbo

Lykke

Steffensen

et al. 2018

Fluids Barriers CNS

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“…7 More than half of the articles (4/7, 57.1%) lacked a specific subgroup analysis for patients with mTBI compared with sTBI and were therefore excluded from this review. [7][8][9][10] Two articles (2/7, 28.6%) lacked published results, with 1 only having an abstract available, 11 whereas another was an RCT protocol with pending results. 12 Subsequently, only 1 study with published results specifically analyzed the subgroup of mTBI patients and the use of HTS.…”

Section: Search Results and Included Study Characteristicsmentioning

confidence: 99%

Hypertonic Saline for Moderate Traumatic Brain Injury: A Scoping Review of Impact on Neurological Deterioration

Rossong

Hasen

Ahmed

et al. 2020

Neurotrauma Reports

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Hypertonic saline (HTS) is a commonly administered agent for intracranial pressure (ICP) control in traumatic brain injury (TBI). The literature on its use is mainly in moderate/severe TBI where invasive ICP monitoring is present. The role of HTS in patients with moderate TBI (mTBI) outside of the intensive care unit (ICU) setting remains unclear. The goal of this scoping review was to provide an overview of the available literature on HTS administration in patients with mTBI without ICP monitoring, assessing its impact on outcome and transitions in care. We performed a scoping systematic review of the literature of MEDLINE, Embase, Scopus, BIOSIS, and the Cochrane Databases from inception to July 31, 2020. We searched for those published articles documenting the administration of HTS in patients with mTBI with recorded functional outcome or transitions in hospital care. A two-step review process was conducted in accordance with methodology outlined in the Cochrane Handbook for Systematic Reviews of Interventions . There were many studies with combined moderate/severe TBI populations. However, most failed to document subgroup analysis for patients with mTBI. Our search strategy identified only one study that documented the administration of HTS in mTBI in which subgroup analysis for mTBI and outcomes were provided. This retrospective cohort study assessed patients with mTBI who did/did not receive prophylactic HTS, finding that those not receiving HTS demonstrated a deterioration in Glasgow Coma Scale (GCS) score in the first 48 h. However, the HTS group did demonstrate a trend to longer hospital stay and pneumonia. Our scoping review identified a significant gap in knowledge surrounding the use of HTS for patients with mTBI without invasive ICP monitoring. The limited identified literature suggests prophylactic administration prevents clinical deterioration, although this is based on a single study with data available for mTBI sub-analysis. Further studies on HTS in non-monitored patients with mTBI are required.

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“…In addition to the previously identified pre-planned analyses, we will examine clinical heterogeneity with primary neurological diagnosis (eg, ischaemic vs traumatic brain injury), disease severity (eg, moderate and severe acute brain injury) and hyperosmolar therapy when given in different doses and/or for different durations (eg, continuous hyperosmolar therapy vs any use) 45 46. If data permit, we will also explore methodological heterogeneity with type of study designs included (eg, randomised controlled trials, observational studies or both).…”

Section: Methods and Analysismentioning

confidence: 99%

Hyperosmolar therapy for acute brain injury: study protocol for an umbrella review of meta-analyses and an evidence mapping

et al. 2020

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IntroductionAcute brain injury is a challenging public health problem worldwide. Elevated intracranial pressure is a common complication after acute brain injury. Hyperosmolar therapy is one of the main therapeutic strategies for the management of intracranial hypertension. This study protocol outlines an umbrella review of meta-analyses which will investigate the benefits and harms of hyperosmolar therapy routinely used for the management of acute brain injury in the intensive care.Methods and analysisWe will search PubMed/MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews. We will include meta-analyses of primary research studies (eg, randomised controlled trials, observational studies or both) that evaluate one or more hyperosmolar solutions (including hypertonic saline and/or mannitol) for the treatment of adult patients with acute brain injury of any severity. Two researchers will independently screen all citations, full-text articles and abstract data. Potential conflicts will be resolved through discussion with a third researcher. Primary outcomes will be mortality and neurological outcomes at discharge. Secondary outcomes will include control of intracranial pressure, cerebral perfusion pressure, length of stay (in hospital an intensive care unit) and any adverse event. Quality of the included meta-analyses will be assessed using the AMSTAR-2 tool. An overall summary of methods and results will be performed using tabular and graphical approaches and will be supplemented by narrative description. We will analyse whether published meta-analyses present an outline of available evidence (eg, cited, described and discussed any previous meta-analysis). Where objectives from two or more meta-analyses overlap, we will assess the causes of any noted discrepancies between meta-analyses.Ethics and disseminationNo ethical approval will be required. Findings from this study will be published in a peer-reviewed journal. All data will be deposited in a cross-disciplinary public repository.PROSPERO registration numberCRD42019148152.

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Association between continuous hyperosmolar therapy and survival in patients with traumatic brain injury – a multicentre prospective cohort study and systematic review

Cited by 49 publications

References 39 publications

Cerebral influx of Na+ and Cl− as the osmotherapy-mediated rebound response in rats

Cerebral influx of Na+ and Cl− as the osmotherapy-mediated rebound response in rats

Hypertonic Saline for Moderate Traumatic Brain Injury: A Scoping Review of Impact on Neurological Deterioration

Hyperosmolar therapy for acute brain injury: study protocol for an umbrella review of meta-analyses and an evidence mapping

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