Hypertonic Saline Lowers Raised Intracranial Pressure in Children After Head Trauma

Fisher, Brock; Thomas, D. G. T.; Peterson, Bradley M.

doi:10.1097/00008506-199201000-00002

Cited by 222 publications

(115 citation statements)

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“…In contrast, hyponatremia accentuates brain damage after traumatic brain injury. [11][12][13][14] Thus, HS therapy is increasingly being used as a therapeutic modality in the neurological critical care setting. In our retrospective case series, 22 continuous HS therapy improved cerebral edema in neurotrauma and postoperative neurosurgical patients.…”

Section: Discussionmentioning

confidence: 99%

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Hypertonic Saline Worsens Infarct Volume After Transient Focal Ischemia in Rats

Bhardwaj

Harukuni

Murphy

et al. 2000

Stroke

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Background and Purpose-Hypertonic saline (HS) has been advocated as a hyperosmolar agent for the treatment of cerebral edema, especially after traumatic brain injury. We tested the hypothesis that continuous intravenous HS administered during reperfusion from transient focal cerebral ischemia attenuates infarct volume. Methods-Halothane-anesthetized male Wistar rats were subjected to 2 hours of middle cerebral artery occlusion (MCAO) by the intraluminal occlusion technique. At the onset of reperfusion, rats received a 10-mL/kg intravenous bolus of 0.9% saline (SAL, nϭ8) or 7.5% SAL (chloride:acetate 50:50, nϭ8) followed by a continuous infusion for 22 hours. In a second series of experiments, ischemic damage was determined in cohorts treated with equivolumetric 3% saline (nϭ8) or 20% mannitol (nϭ8). In a third series, regional cerebral blood flow was measured ([ 14 C]iodoantipyrine autoradiography) at 6 hours of reperfusion in 7.5%-SAL-treated (nϭ5) or SAL-treated (nϭ5) animals. Results-In SAL rats, serum Na ϩ was 137Ϯ3 and 138Ϯ2 mEq/L (meanϮSEM) at baseline and 22 hours of reperfusion, respectively. In 7.5% SAL, serum Na ϩ was 136Ϯ2 and 154Ϯ2 mEq/L at baseline and reperfusion, respectively. Physiological variables and reduction in laser-Doppler signal during MCAO and early reperfusion were not different between the 2 treatment groups. Cortical infarct volume was larger in 7.5%-SAL-treated rats (121Ϯ14 mm 3 ; 30Ϯ3% of contralateral cortex; PϽ0.05) than in SAL (64Ϯ15 mm 3 ; 16Ϯ4% of contralateral cortex). Striatal infarct volume was unchanged by HS therapy. Ipsilateral cortical tissue volume was increased relative to the contralateral side (by 26Ϯ5% with SAL; by 41Ϯ5% with 7.5% SAL). In contrast, ischemic damage was unaffected by 3%-SAL or 20%-mannitol treatment compared with SAL. Regional cerebral blood flow during reperfusion was heterogeneous in all animals, but there was no evidence of postischemic hypoperfusion or blood flow maldistribution in 7.5%-SAL-treated animals.Conclusions-These data demonstrate that hypernatremia resulting from postischemic HS infusion worsens cortical infarct volume in transient focal cerebral ischemia. The deleterious effect is not linked to exacerbation of delayed hypoperfusion during early reperfusion (6 hours); however, blood flow defects at later recovery time points remain to be excluded. These results may have implications for HS therapy in clinical ischemic stroke. (Stroke.

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Section: Discussionmentioning

confidence: 99%

“…8 -10 Furthermore, several case series and randomized clinical trials have demonstrated improved outcome with HS therapy in traumatic brain injury. [11][12][13][14] Therefore, it has been hypothesized that HS therapy could be beneficial in cerebral ischemia and stroke.…”

Section: See Editorial Comment Page 1701mentioning

confidence: 99%

Hypertonic Saline Worsens Infarct Volume After Transient Focal Ischemia in Rats

Bhardwaj

Harukuni

Murphy

et al. 2000

Stroke

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“…Hypertonic saline solutions have the advantage of lowering raised ICP in the same range as mannitol with an associated effect of low volume resuscitation that can be mostly useful when hemodynamic instability is present. 17,18 Direct ventricular puncture is another means of decreasing raised intracranial pressure that could be performed rapidly at the bedside. However, acute drainage resulting in ventricular collapse could result in a rapidly growing intraparenchymal hemorrhage and brain herniation.…”

Section: Discussionmentioning

confidence: 99%

Emergency management of deeply comatose children with acute rupture of cerebral arteriovenous malformations

Meyer

Orliaguet

Zérah

et al. 2000

Can J Anesth/J Can Anesth

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REPORTS O F INVESTIGATIONCAN J ANESTH 2000 / 47: 8 / pp [758][759][760][761][762][763][764][765][766] Purpose: To assess the impact of emergency management on mortality and morbidity of acute rupture of cerebral arteriovenous malformations resulting in deep coma in children, and the factors predicting outcome. Methods: Retrospective chart review of 20 children with a Glasgow Coma Scale # 8 with acute hemorrhagic stroke from a cerebral arteriovenous malformation rupture was conducted. Protocol included: early resuscitation with tracheal intubation and ventilation after induction of anesthesia with sufentanil, and benzodiazepine, and mannitol 20% or hypertonic saline 7.5% infusion for life-threatening brain herniation. Radiological exploration was limited to contrast-enhanced CT scan preceding immediate surgical decompression. Postoperatively, children were deeply sedated and intracranial pressure monitoring allowed titration with osmotherapy , vasopressors, hyperventilation or barbiturate coma to control cerebral perfusion pressure. Analysis used stratification of the type of hemorrhage (supra or infra tentorial), location (intraparenchymal and subarachnoid, intraparenchymal and intraventricular or intraventricular alone) and relationship between presentation, evolution with resuscitation, type of cerebral lesion, and outcome. Results: Patients had a severe initial presentation (median Glasgow Coma Scale five), eight had unilateral and eight bilateral third nerve palsy. Compressive hematoma in supratentorial localisation represented 75% of the cases. Global mortality was 40%. Persistence of mydriasis after resuscitation increased mortality to 75%. Massive intraventricular flooding was associated with increased mortality. Good functional outcome was achieved in survivors. Conclusion: Acute rupture of an AVM can result in rapidly progressing coma. Emergency management with early resuscitation, minimal radiological exploration before rapid surgical decompression results in a mortality rate of 40%, but a good functional outcome can be expected in the survivors.Objectif : Évaluer l'effet et le pronostic d'une intervention d'urgence sur la mortalité et la morbidité d'une rupture imprévisible de malformations artérioveineuses cérébrales qui ont conduit à un coma profond chez des enfants. Méthode : Un examen rétrospectif des dossiers de 20 enfants, cotés # 8 à l'échelle de Glasgow, qui ont subi un accident hémorragique aigu causé par la rupture de malformations artérioveineuses cérébrales, a été réalisé. Le protocole comportait : une réanimation précoce, une intubation endotrachéale et une ventilation après l'induction de l'anesthésie avec du sufentanil, du mannitol à 20 % ou une perfusion salée hypertonique à 7,5 % pour traiter l'hernie cérébrale grave. L'exploration radiologique s'est limitée à la scanographie de prise de contraste juste avant la décompression chirurgicale. Après l'opération, les enfants ont reçu une forte sédation. Le monitorage de la pression intracrânienne a permis le titrage de l'osmothérapie, des ...

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“…One small (n = 9) RCT investigating temperature-corrected versus uncorrected ventilatory management, reporting no difference on ICP 72 ; Four hypothermia vs. normothermia RCTs, [73][74][75][76] including the recent ''Cool Kids'' RCT 74 that was ceased for futility, reporting no difference between groups on mortality, GOS, ICP (three RCTs) and LOS (one RCT); One RCT of immune-enhancing formula, reporting no difference between groups on early mortality or hospital LOS 77 ; Two small (n < 33), single center RCTs of hypertonic saline vs. normal saline 78 /lactated Ringer's solution, 79 which found mixed results on ICP (one positive, one with no statistically significant difference between groups), positive results on ICU LOS (one RCT) and no difference between groups on mortality and hospital LOS (one RCT); One RCT of phenobarbitone, which reported no difference on mortality or ICP 80 ; One RCT of dexamethasone, which reported no difference on ICP or 6-month GOS 81 ; One RCT of decompressive craniectomy (DC) versus standard care, which did not report any difference between groups on ICP, ICU, or hospital LOS or GOS. 82 …”

Section: Pediatric Rctsmentioning

confidence: 99%

A State-of-the-Science Overview of Randomized Controlled Trials Evaluating Acute Management of Moderate-to-Severe Traumatic Brain Injury

Bragge

Synnot²,

Maas

et al. 2016

Journal of Neurotrauma

102

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Moderate-to-severe traumatic brain injury (TBI) remains a major global challenge, with rising incidence, unchanging mortality and lifelong impairments. State-of-the-science reviews are important for research planning and clinical decision support. This review aimed to identify randomized controlled trials (RCTs) evaluating interventions for acute management of moderate/severe TBI, synthesize key RCT characteristics and findings, and determine their implications on clinical practice and future research. RCTs were identified through comprehensive database and other searches. Key characteristics, outcomes, risk of bias, and analysis approach were extracted. Data were narratively synthesized, with a focus on robust (multi-center, low risk of bias, n > 100) RCTs, and three-dimensional graphical figures also were used to explore relationships between RCT characteristics and findings. A total of 207 RCTs were identified. The 191 completed RCTs enrolled 35,340 participants (median, 66). Most (72%) were single center and enrolled less than 100 participants (69%). There were 26 robust RCTs across 18 different interventions. For 74% of 392 comparisons across all included RCTs, there was no significant difference between groups. Positive findings were broadly distributed with respect to RCT characteristics. Less than one-third of RCTs demonstrated low risk of bias for random sequence generation or allocation concealment, less than one-quarter used covariate adjustment, and only 7% employed an ordinal analysis approach. Considerable investment of resources in producing 191 completed RCTs for acute TBI management has resulted in very little translatable evidence. This may result from broad distribution of research effort, small samples, preponderance of single-center RCTs, and methodological shortcomings. More sophisticated RCT design, large multi-center RCTs in priority areas, increased focus on pre-clinical research, and alternatives to RCTs, such as comparative effectiveness research and precision medicine, are needed to fully realize the potential of acute TBI research to benefit patients.

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Hypertonic Saline Lowers Raised Intracranial Pressure in Children After Head Trauma

Cited by 222 publications

References 0 publications

Hypertonic Saline Worsens Infarct Volume After Transient Focal Ischemia in Rats

Hypertonic Saline Worsens Infarct Volume After Transient Focal Ischemia in Rats

Emergency management of deeply comatose children with acute rupture of cerebral arteriovenous malformations

A State-of-the-Science Overview of Randomized Controlled Trials Evaluating Acute Management of Moderate-to-Severe Traumatic Brain Injury

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