Early Osmotherapy in Severe Traumatic Brain Injury: An International Multicenter Study

Anstey, James; Taccone, Fabio Silvio; Udy, Andrew; Citerio, Giuseppe; Duranteau, Jacques; Ichai, Carole; Badenes, Rafael; Prowle, John R.; Ercole, Ari; Oddo, Mauro; Schneider, Antoine; Jagt, Mathieu van der; Wolf, Stefan; Helbok, Raimund; Nelson, David W.; Skrifvars, M.B.; Harrois, Anatole; Presneill, Jeffrey; Cooper, Jamie; Bailey, Michael; Bellomo, Rinaldo

doi:10.1089/neu.2019.6399

Cited by 18 publications

(8 citation statements)

References 15 publications

(19 reference statements)

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“…Our analysis was different and focused on clinical outcomes, as a result of preference for one of the HOAs and likewise seems to underpin current practices and guidelines. Contrary to our ndings, Anstey et al [27] found that patients who received mannitol compared to patients who received HTS had a higher Marshall CT score (4 versus 3), a higher ISS (42 versus 32) and had a higher predicted probability of 6month mortality using the extended IMPACT score (35% versus 25%) [27]. We did not nd such differences between the group of patients who received mannitol or HTS supporting random variability.…”

Section: Discussioncontrasting

confidence: 89%

Mannitol or Hypertonic Saline in Traumatic Brain Injury patients: a CENTER-TBI study

Veen

Nieboer

Kompanje

et al. 2022

Preprint

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Introduction: Increased intracranial pressure (ICP) is one of the most important modifiable and immediate threats to critically ill patients suffering from traumatic brain injury (TBI). Two hyperosmolar agents (HOA), mannitol and hypertonic saline (HTS) are routinely used in clinical practice to treat increased ICP. We aimed to assess whether a preference for mannitol, HTS or their combined use translated into differences in (functional) outcome.Methods: The CENTER-TBI Study is a prospective multicenter cohort study. For this study, patients with TBI, admitted to the ICU, treated with mannitol and/or HTS, aged ≥16, were included. Patients and centers were differentiated based on treatment preference with mannitol and/or HTS based on structured, data-driven criteria such as first administered HOA at the ICU. We assessed influence of center and patient characteristics in the choice of agent using adjusted multivariate models. Furthermore, we assessed the influence of HOA preference on (functional) outcome using adjusted ordinal and logistic regression models, and instrumental variable analyses.Results: In total, 2056 patients were assessed. Of these, 502 (24%) patients received mannitol and/or HTS on the ICU. The first bolus of a HOA was HTS for 287 (57%) patients, mannitol for 149 (30%) patients, and both for 66 (13%) patients. Two unreactive pupils were more common for patients receiving both (13, 21%), compared to patients receiving HTS (40, 14%), or mannitol (22, 16%). Center, rather than patient characteristics, was independently associated with the preferred choice of HOA (p-value < 0.05). ICU mortality and 6-month functional outcome were similar between patients preferably treated with mannitol compared to HTS (OR = 0.8, CI = 0.4 – 1.7; OR = 1.1, CI = 0.7 – 1.8 respectively). Patients who received both also had a similar ICU mortality and 6-month functional outcome compared to patients receiving HTS (OR = 1.9, CI = 0.7 - 4.9; OR = 0.7, CI = 0.3 – 1.6 respectively).Conclusion: We found between center variability regarding HOA preference. Moreover, we found that center is a more important driver of the choice of HOA than patient characteristics. However, our study indicates that this variability is an acceptable practice given absence of differences in outcomes associated with a specific HOA.

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Section: Discussioncontrasting

confidence: 89%

Mannitol or Hypertonic Saline in Traumatic Brain Injury patients: a CENTER-TBI study

Veen

Nieboer

Kompanje

et al. 2022

Preprint

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“…Our participants represent a broad spectrum of patients with serious TBI; demographics, mechanisms of injury, and injury characteristics were similar to those of other international cohorts. [23][24][25] Among those patients matching DECRA eligibility (in whom DC may increase survival with severe disability), we observed infrequent use of secondary DC, in keeping with contemporary evidence and guidelines. However, most patients in our study had injury characteristics that would have excluded them from both DECRA and RESCUEicp.…”

Section: Relationship To Previous Studiessupporting

confidence: 82%

Decompressive Craniectomy Practice following Traumatic Brain Injury in Comparison with Randomized Trials: Harmonized, Multi-Center Cohort Studies in Europe, the United Kingdom, and Australia

Gantner

Wiegers

Bragge

et al. 2022

Journal of Neurotrauma

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High quality evidence shows decompressive craniectomy (DC) following traumatic brain injury (TBI) may improve survival but increase the number of severely disabled survivors. Contemporary international practice is unknown. We sought to describe international use of DC, and the alignment with evidence and clinical practice guidelines, by analyzing the harmonized Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) and Australia-Europe NeuroTrauma Effectiveness Research in Traumatic Brain Injury (OzENTER-TBI) core study datasets, which include patients admitted to intensive care units (ICUs) in Europe, the United Kingdom, and Australia between 2015 and 2017. Outcomes of interest were treatment with DC relative to clinical trial evidence and the Brain Trauma Foundation guidelines. Of 2336 people admitted to ICUs following TBI, DC was performed in 320 (13.7%): in 64/1422 (4.5%) patients with diffuse TBI and 195/640 (30.5%) patients with traumatic mass lesions. Secondary DC (for treatment of intracranial hypertension) was used infrequently in patients who met enrollment criteria of the two randomized clinical trials informing the guidelines-specifically, in 11/124 (8.9%) of those matching Decompressive Craniectomy in Diffuse Traumatic Brain Injury trial (DECRA) enrollment, and in 30/224 (13.4%) of those matching Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intracranial Pressure (RESCUEicp). Of patients who underwent DC, 258/320 (80.6%) were ineligible for either trial: 149/320 (46.6%) underwent primary DC, 62/320 (19.4%) were outside the trials' age criteria, and 126/320 (39.4%) did not develop intracranial hypertension refractory to non-operative therapies prior to

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“…We retrospectively collected data on previously managed patients in 14 Intensive Care Units (ICUs) treating TBI patients. The description of data collection has been described previously [10].…”

Section: Study Populationmentioning

confidence: 99%

“…We collected six-hourly serum sodium concentrations from ICU admission until 7 days, or death, whichever came first. We collected data on important aspects of TBI care including neurosurgery (clot evacuation, extra-ventricular drainage, decompressive craniectomy) as well as the use of osmotherapy [10], barbiturate coma and hypothermia (less than 35°C) and daily total desmopressin administered. Finally, we collected outcome data including ICU and hospital mortality, and ICU and hospital length of stay.…”

Section: Data Collectionmentioning

confidence: 99%

Variability in Serum Sodium Concentration and Prognostic Significance in Severe Traumatic Brain Injury: A Multicenter Observational Study

et al. 2020

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Background/Objective: Dysnatremia is common in severe traumatic brain injury (TBI) patients and may contribute to mortality. However, serum sodium variability has not been studied in TBI patients. We hypothesized that such variability would be independently associated with mortality.Methods: We collected 6-hourly serum sodium levels for the first 7 days of ICU admission from 240 severe TBI patients in 14 neurotrauma ICUs in Europe and Australia. We evaluated the association between daily serum sodium standard deviation (dNaSD), an index of variability, and 28-day mortality.Results: Patients were 46 ± 19 years of age with a median initial GCS of 6 [4 -8]. Overall hospital mortality was 28%. Hypernatremia and hyponatremia occurred in 64% and 24% of patients, respectively. Over the first 7 days in ICU, serum sodium standard deviation was 2.8 [2.0 -3.9] mmol/L. Maximum daily serum sodium standard deviation (dNaSD) occurred at a median of 2 [1-4] days after admission. There was a significant progressive decrease in dNaSD over the first 7 days (coefficient -0.15 95%CI [-0.18 --0.12], p<0.001). After adjusting for baseline TBI severity, diabetes insipidus, the use of osmotherapy, the occurrence of hypernatremia and hyponatremia and center, dNaSD was significantly independently associated with 28-day mortality (HR 1.27 95%CI (1.01-1.61), p=0.048).Conclusions: Our study demonstrates that daily serum sodium variability is an independent predictor of 28-day mortality in severe TBI patients. Further prospective investigations are 5 necessary to confirm the significance of sodium variability in larger cohorts of TBI patients and test whether attenuating such variability confers outcome benefits to such patients.

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Early Osmotherapy in Severe Traumatic Brain Injury: An International Multicenter Study

Cited by 18 publications

References 15 publications

Mannitol or Hypertonic Saline in Traumatic Brain Injury patients: a CENTER-TBI study

Mannitol or Hypertonic Saline in Traumatic Brain Injury patients: a CENTER-TBI study

Decompressive Craniectomy Practice following Traumatic Brain Injury in Comparison with Randomized Trials: Harmonized, Multi-Center Cohort Studies in Europe, the United Kingdom, and Australia

Variability in Serum Sodium Concentration and Prognostic Significance in Severe Traumatic Brain Injury: A Multicenter Observational Study

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