scholarly journals Hypertonic Saline is Superior to Mannitol for the Combined Effect on Intracranial Pressure and Cerebral Perfusion Pressure Burdens in Patients With Severe Traumatic Brain Injury

Neurosurgery ◽  
2019 ◽  
Vol 86 (2) ◽  
pp. 221-230 ◽  
Author(s):  
Halinder S Mangat ◽  
Xian Wu ◽  
Linda M Gerber ◽  
Justin T Schwarz ◽  
Malik Fakhar ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
New York ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Cerebral Perfusion Pressure ◽  
Hypertonic Saline ◽  
Severe Traumatic Brain Injury ◽  
Cerebral Perfusion ◽  
Perfusion Pressure ◽  
Severe Tbi

Abstract BACKGROUND Hypertonic saline (HTS) and mannitol are effective in reducing intracranial pressure (ICP) after severe traumatic brain injury (TBI). However, their simultaneous effect on the cerebral perfusion pressure (CPP) and ICP has not been studied rigorously. OBJECTIVE To determine the difference in effects of HTS and mannitol on the combined burden of high ICP and low CPP in patients with severe TBI. METHODS We performed a case–control study using prospectively collected data from the New York State TBI-trac® database (Brain Trauma Foundation, New York, New York). Patients who received only 1 hyperosmotic agent, either mannitol or HTS for raised ICP, were included. Patients in the 2 groups were matched (1:1 and 1:2) for factors associated with 2-wk mortality: age, Glasgow Coma Scale score, pupillary reactivity, hypotension, abnormal computed tomography scans, and craniotomy. Primary endpoint was the combined burden of ICPhigh (> 25 mm Hg) and CPPlow (< 60 mm Hg). RESULTS There were 25 matched pairs for 1:1 comparison and 24 HTS patients matched to 48 mannitol patients in 1:2 comparisons. Cumulative median osmolar doses in the 2 groups were similar. In patients treated with HTS compared to mannitol, total number of days (0.6 ± 0.8 vs 2.4 ± 2.3 d, P < .01), percentage of days with (8.8 ± 10.6 vs 28.1 ± 26.9%, P < .01), and the total duration of ICPhigh + CPPlow (11.12 ± 14.11 vs 30.56 ± 31.89 h, P = .01) were significantly lower. These results were replicated in the 1:2 match comparisons. CONCLUSION HTS bolus therapy appears to be superior to mannitol in reduction of the combined burden of intracranial hypertension and associated hypoperfusion in severe TBI patients.

DOES ADHERENCE TO TREATMENT TARGETS IN CHILDREN WITH SEVERE TRAUMATIC BRAIN INJURY AVOID BRAIN HYPOXIA? A BRAIN TISSUE OXYGENATION STUDY

Neurosurgery ◽  
2008 ◽  
Vol 63 (1) ◽  
pp. 83-92 ◽  
Author(s):  
Anthony A. Figaji ◽  
A. Graham Fieggen ◽  
Andrew C. Argent ◽  
Peter D. LeRoux ◽  
Jonathan C. Peter
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Brain Tissue ◽  
Cerebral Perfusion Pressure ◽  
Cerebral Perfusion ◽  
Perfusion Pressure ◽  
Treatment Targets ◽  
Poor Outcome ◽  
Severe Tbi

ABSTRACT OBJECTIVE Most physicians rely on conventional treatment targets for intracranial pressure, cerebral perfusion pressure, systemic oxygenation, and hemoglobin to direct management of traumatic brain injury (TBI) in children. In this study, we used brain tissue oxygen tension (PbtO2) monitoring to examine the association between PbtO2 values and outcome in pediatric severe TBI and to determine the incidence of compromised PbtO2 in patients for whom acceptable treatment targets had been achieved. METHODS In this prospective observational study, 26 children with severe TBI and a median postresuscitation Glasgow Coma Scale score of 5 were managed with continuous PbtO2 monitoring. The relationships between outcome and the 6-hour period of lowest PbtO2 values and the length of time that PbtO2 was less than 20, 15, 10, and 5 mmHg were examined. The incidence of reduced PbtO2 for each threshold was evaluated where the following targets were met: intracranial pressure less than 20 mmHg, cerebral perfusion pressure greater than 50 mmHg, arterial oxygen tension greater than 60 mmHg (and peripheral oxygen saturation > 90%), and hemoglobin greater than 8 g/dl. RESULTS There was a significant association between poor outcome and the 6-hour period of lowest PbtO2 and length of time that PbtO2 was less than 15 and 10 mmHg. Multiple logistic regression analysis showed that low PbtO2 had an independent association with poor outcome. Despite achieving the management targets described above, 80% of patients experienced one or more episodes of compromised PbtO2 (< 20 mmHg), and almost one-third experienced episodes of brain hypoxia (PbtO2 < 10 mmHg). CONCLUSION Reduced PbtO2 is associated with poor outcome in pediatric severe TBI. In addition, many patients experience episodes of compromised PbtO2 despite achieving acceptable treatment targets.

scholarly journals Acute clinical grading in pediatric severe traumatic brain injury and its association with subsequent intracranial pressure, cerebral perfusion pressure, and brain oxygenation

2008 ◽  
Vol 25 (4) ◽  
pp. E4 ◽  
Author(s):  
Anthony A. Figaji ◽  
Eugene Zwane ◽  
A. Graham Fieggen ◽  
Jonathan C. Peter ◽  
Peter D. Leroux
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Cerebral Perfusion Pressure ◽  
Severe Traumatic Brain Injury ◽  
Cerebral Perfusion ◽  
Perfusion Pressure ◽  
Brain Oxygenation ◽  
Clinical Scores ◽  
The Relationship

Object The goal of this paper was to examine the relationship between methods of acute clinical assessment and measures of secondary cerebral insults in severe traumatic brain injury in children. Methods Patients who underwent intracranial pressure (ICP), cerebral perfusion pressure (CPP), and brain oxygenation (PbtO2) monitoring and who had an initial Glasgow Coma Scale score, Pediatric Trauma Score, Pediatric Index of Mortality 2 score, and CT classification were evaluated. The relationship between these acute clinical scores and secondary cerebral insult measures, including ICP, CPP, PbtO2, and systemic hypoxia were evaluated using univariate and multivariate analysis. Results The authors found significant associations between individual acute clinical scores and select physiological markers of secondary injury. However, there was a large amount of variability in these results, and none of the scores evaluated predicted each and every insult. Furthermore, a number of physiological measures were not predicted by any of the scores. Conclusions Although they may guide initial treatment, grading systems used to classify initial injury severity appear to have a limited value in predicting who is at risk for secondary cerebral insults.

Sign in / Sign up

Export Citation Format

Share Document