Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury

OBJECT Increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI) is associated with a higher mortality rate and poor outcome. Mannitol and hypertonic saline (HTS) have both been used to treat high ICP, but it is unclear which one is more effective. Here, the authors compare the effect of mannitol versus HTS on lowering the cumulative and daily ICP burdens after severe TBI. METHODS The Brain Trauma Foundation TBI-trac New York State database was used for this retrospective study. Patients with severe TBI and intracranial hypertension who received only 1 type of hyperosmotic agent, mannitol or HTS, were included. Patients in the 2 groups were individually matched for Glasgow Coma Scale score (GCS), pupillary reactivity, craniotomy, occurrence of hypotension on Day 1, and the day of ICP monitor insertion. Patients with missing or erroneous data were excluded. Cumulative and daily ICP burdens were used as primary outcome measures. The cumulative ICP burden was defined as the total number of days with an ICP of > 25 mm Hg, expressed as a percentage of the total number of days of ICP monitoring. The daily ICP burden was calculated as the mean daily duration of an ICP of > 25 mm Hg, expressed as the number of hours per day. The numbers of intensive care unit (ICU) days, numbers of days with ICP monitoring, and 2-week mortality rates were also compared between the groups. A 2-sample t-test or chi-square test was used to compare independent samples. The Wilcoxon signed-rank or Cochran-Mantel-Haenszel test was used for comparing matched samples. RESULTS A total of 35 patients who received only HTS and 477 who received only mannitol after severe TBI were identified. Eight patients in the HTS group were excluded because of erroneous or missing data, and 2 other patients did not have matches in the mannitol group. The remaining 25 patients were matched 1:1. Twenty-four patients received 3% HTS, and 1 received 23.4% HTS as bolus therapy. All 25 patients in the mannitol group received 20% mannitol. The mean cumulative ICP burden (15.52% [HTS] vs 36.5% [mannitol]; p = 0.003) and the mean (± SD) daily ICP burden (0.3 ± 0.6 hours/day [HTS] vs 1.3 ± 1.3 hours/day [mannitol]; p = 0.001) were significantly lower in the HTS group. The mean (± SD) number of ICU days was significantly lower in the HTS group than in the mannitol group (8.5 ± 2.1 vs 9.8 ± 0.6, respectively; p = 0.004), whereas there was no difference in the numbers of days of ICP monitoring (p = 0.09). There were no significant differences between the cumulative median doses of HTS and mannitol (p = 0.19). The 2-week mortality rate was lower in the HTS group, but the difference was not statistically significant (p = 0.56). CONCLUSIONS HTS given as bolus therapy was more effective than mannitol in lowering the cumulative and daily ICP burdens after severe TBI. Patients in the HTS group had significantly lower number of ICU days. The 2-week mortality rates were not statistically different between the 2 groups.

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Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

Journal of Neurosurgery ◽

10.3171/2012.7.jns111816 ◽

2012 ◽

Vol 117 (4) ◽

pp. 729-734 ◽

Cited By ~ 103

Author(s):

Arash Farahvar ◽

Linda M. Gerber ◽

Ya-Lin Chiu ◽

Nancy Carney ◽

Roger Härtl ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Intracranial Hypertension ◽

Severe Traumatic Brain Injury ◽

Lower Mortality ◽

Icp Monitoring ◽

Improvement Program ◽

Severe Tbi ◽

Gcs Score

Object Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe traumatic brain injury (TBI), but there is limited evidence that monitoring and treating intracranial hypertension reduces mortality. This study uses a large, prospectively collected database to examine the effect on 2-week mortality of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP monitor. Methods From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score <9), 1446 patients were treated with ICP-lowering therapies. Of those, 1202 had an ICP monitor inserted and 244 were treated without monitoring. Patients were admitted to one of 20 Level I and two Level II trauma centers, part of a New York State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009. This database also contains information on known independent early prognostic indicators of mortality, including age, admission GCS score, pupillary status, CT scanning findings, and hypotension. Results Age, initial GCS score, hypotension, and CT scan findings were associated with 2-week mortality. In addition, patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 0.02) than those treated without an ICP monitor, after adjusting for parameters that independently affect mortality. Conclusions In patients with severe TBI treated for intracranial hypertension, the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor. Based on these findings, the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring.

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Intracranial Pressure Monitoring in Severe Traumatic Brain Injury – Results of a Canadian Survey

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100052252 ◽

2000 ◽

Vol 27 (2) ◽

pp. 143-147 ◽

Cited By ~ 22

Author(s):

Ramesh Sahjpaul ◽

Murray Girotti

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Prospective Trial ◽

Icp Monitoring ◽

Pressure Monitoring ◽

Level Of Confidence ◽

Routine Monitoring ◽

Severe Tbi ◽

High Level

ABSTRACT:Objective:The purpose of this study was to obtain information from Canadian neurosurgeons regarding their opinions on, and utilization of, intracranial pressure (ICP) monitoring for severe traumatic brain injury (TBI).Methods:A brief survey was sent to practicing Canadian neurosurgeons questioning them about their utilization of, and confidence in, intracranial pressure monitoring in the management of patients with severe TBI.Results:One hundred and ninety-six surveys were mailed. There were 103 responses for a response rate of 52.6%. The vast majority of responding neurosurgeons (98.1%) utilized ICP monitoring in the management of patients with severe TBI, with most (63.4%) using it in more than 75% of their patients, 14.9% using it in 50-75% of patients, 14.9% in 25-50% of patients, and 6.9% using it in less than 25% of patients. The level of confidence that routine monitoring improves outcome from severe TBI ranged from 23.3% having a low level of confidence, 56.3% having an intermediate level of confidence, to 20.4% having a high level of confidence. Most respondents (78.6%) felt that some form of prospective trial evaluating the role of ICP monitoring in improving outcome from severe TBI was warranted; 17.4% felt such a trial was not warranted and 3.9% were uncertain.Conclusions:While ICP monitoring has gained almost universal acceptance among responding Canadian neurosurgeons, their level of confidence that routine monitoring improves outcome from severe TBI was quite variable, with only 20.4% of respondents having a high level of confidence. Over 75% of respondents felt that some form of prospective trial evaluating the utility of ICP monitoring is warranted. This information is being used in consideration of a prospective trial addressing this issue.

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Intracranial Pressure Monitors in Traumatic Brain Injury: A Systematic Review

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100015286 ◽

2012 ◽

Vol 39 (5) ◽

pp. 571-576 ◽

Cited By ~ 29

Author(s):

Asher A. Mendelson ◽

Chris Gillis ◽

William R. Henderson ◽

Juan J. Ronco ◽

Vinay Dhingra ◽

...

Keyword(s):

Systematic Review ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Observational Studies ◽

Pooled Analysis ◽

Point Estimate ◽

Icp Monitoring ◽

Study Heterogeneity ◽

Severe Tbi

We conducted a systematic review to examine the relationship between intracranial pressure monitors (ICP) monitors and mortality in traumatic brain injury (TBI). We systematically searched for articles that met the following criteria: (1) adults patients, (2) TBI, (3) use of an ICP monitor, (4) point estimate for mortality with ICP monitoring (5) adjustment for potential confounders. Six observational studies were identified with 11,371 patients. There was marked between-study heterogeneity that precluded a pooled analysis. Patients with ICP monitors had different clinical characteristics and received more ICP targeted therapy in the ICU. Four studies found no significant relationship between ICP monitoring and survival, while the other two studies demonstrated conflicting results. Significant confounding by indication in observational studies limits the examination of isolated TBI interventions. More research should focus on interventions that affect TBI careplan systems. Further research is needed to identify which subset of severe TBI patients may benefit from ICP monitoring.

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The role of ICP monitoring in meningitis

Neurosurgical FOCUS ◽

10.3171/2017.8.focus17419 ◽

2017 ◽

Vol 43 (5) ◽

pp. E7 ◽

Cited By ~ 10

Author(s):

Areej Tariq ◽

Pedro Aguilar-Salinas ◽

Ricardo A. Hanel ◽

Neeraj Naval ◽

Mohamad Chmayssani

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Mortality Rate ◽

Intracranial Hypertension ◽

Clinical Outcomes ◽

Icp Monitoring ◽

Review Of The Literature ◽

Cns Infections

Intracranial pressure (ICP) monitoring has been widely accepted in the management of traumatic brain injury. However, its use in other pathologies that affect ICP has not been advocated as strongly, especially in CNS infections. Despite the most aggressive and novel antimicrobial therapies for meningitis, the mortality rate associated with this disease is far from satisfactory. Although intracranial hypertension and subsequent death have long been known to complicate meningitis, no specific guidelines targeting ICP monitoring are available. A review of the literature was performed to understand the pathophysiology of elevated ICP in meningitis, diagnostic challenges, and clinical outcomes in the use of ICP monitoring.

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Comparison of mannitol and hypertonic saline in the treatment of severe brain injuries

Journal of Neurosurgery ◽

10.3171/2010.5.jns091685 ◽

2011 ◽

Vol 114 (2) ◽

pp. 545-548 ◽

Cited By ~ 72

Author(s):

Nikolaos Sakellaridis ◽

Elias Pavlou ◽

Stylianos Karatzas ◽

Despina Chroni ◽

Konstantinos Vlachos ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Hypertonic Saline ◽

Severe Traumatic Brain Injury ◽

Brain Injuries ◽

Treatment Protocol ◽

Venous Catheter ◽

Duration Of Action ◽

The Mean

Object The purpose of this study was to compare the effects of mannitol and hypertonic saline in doses of similar osmotic burden for the treatment of intracranial hypertension in patients with severe traumatic brain injury. Methods The authors used an alternating treatment protocol to compare the effect of hypertonic saline with that of mannitol given for episodes of increased intracranial pressure in patients treated for severe head injury at their hospital during 2006–2008. Standard guidelines for the management of severe traumatic brain injury were followed. Elevated intracranial pressure (ICP) was treated either with mannitol or hypertonic saline. Doses of similar osmotic burden (mannitol 20%, 2 ml/kg, infused over 20 minutes, or saline 15%, 0.42 ml/kg, administered as a bolus via a central venous catheter) were given alternately to the individual patient with severe brain injury during episodes of increased pressure. The dependent variables were the extent and duration of reduction of increased ICP. The choice of agent for treatment of the initial hypertensive event was determined on a randomized basis; treatment was alternated for every subsequent event in each individual patient. Reduction of ICP and duration of action were recorded after each event. Results obtained after mannitol administration were statistically compared with those obtained after hypertonic saline administration. Results Data pertaining to 199 hypertensive events in 29 patients were collected. The mean decrease in ICP obtained with mannitol was 7.96 mm Hg and that obtained with hypertonic saline was 8.43 mm Hg (p = 0.586, equal variances assumed). The mean duration of effect was 3 hours 33 minutes for mannitol and 4 hours 17 minutes for hypertonic saline (p = 0.40, equal variances assumed). Conclusions No difference between the 2 medications could be found with respect to the extent of reduction of ICP or duration of action.

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Prognostic Impact of Intracranial Pressure Monitoring in Patients with Severe Traumatic Brain Injury

Arquivos Brasileiros de Neurocirurgia Brazilian Neurosurgery ◽

10.1055/s-0038-1675365 ◽

2018 ◽

Vol 37 (04) ◽

pp. 291-296

Author(s):

Bárbara Borchardt ◽

Luanna Freitas ◽

Ademar Filho ◽

Áurea da Rosa ◽

Milena Gabe ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Severe Traumatic Brain Injury ◽

Total Sample ◽

Common Finding ◽

Prognostic Impact ◽

Icp Monitoring ◽

Severe Tbi ◽

Improvement In Survival

Objectives The aim of the present study was to analyze the prognostic impact of intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury (TBI). Methods An observational, retrospective and quantitative study was performed. The sample consisted of 246 patients diagnosed with severe TBI, from January 2009 to August 2017. Results Out of the total sample, 43.56% of the patients were submitted to ICP monitoring. The mean time of use of the catheter was 1.7 days. In both groups, males were the most affected, and the majority of the patients were < 50 years old. Automobile accident was the main etiology of TBI. In the initial clinical evaluation, mydriatic pupils were related to death and normal pupil reaction at hospital discharge. The monitored group performed a larger number of computed tomography (CT) scans, with a mean of 2.6 examinations, with cerebral edema being the most common finding. Regarding the prognosis, those who used a catheter for ICP monitoring had a 47% reduction in the chance of death when compared with those who did not use the catheter. The stay duration both in the hospital and in the intensive care units was higher in patients who underwent ICP monitoring; periods > 30 days were related to meningitis, especially in those who used the catheter. Conclusion Patients who used a catheter for ICP monitoring had a significant improvement in survival.

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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 ◽

10.1093/neuros/nyz046 ◽

2019 ◽

Vol 86 (2) ◽

pp. 221-230 ◽

Cited By ~ 13

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.

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Intracranial pressure monitoring among children with severe traumatic brain injury

Journal of Neurosurgery Pediatrics ◽

10.3171/2015.3.peds14507 ◽

2015 ◽

Vol 16 (5) ◽

pp. 523-532 ◽

Cited By ~ 15

Author(s):

Aziz S. Alali ◽

David Gomez ◽

Chethan Sathya ◽

Randall S. Burd ◽

Todd G. Mainprize ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Observational Study ◽

Hospital Mortality ◽

Pediatric Trauma ◽

Trauma Centers ◽

Icp Monitoring ◽

Hospital Level ◽

Severe Tbi

OBJECT Well-designed studies linking intracranial pressure (ICP) monitoring with improved outcomes among children with severe traumatic brain injury (TBI) are lacking. The main objective of this study was to examine the relationship between ICP monitoring in children and in-hospital mortality following severe TBI. METHODS An observational study was conducted using data derived from 153 adult or mixed (adult and pediatric) trauma centers participating in the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) and 29 pediatric trauma centers participating in the pediatric pilot TQIP between 2010 and 2012. Random-intercept multilevel modeling was used to examine the association between ICP monitoring and in-hospital mortality among children with severe TBI ≤16 years of age after adjusting for important confounders. This association was evaluated at the patient level and at the hospital level. In a sensitivity analysis, this association was reexamined in a propensity-matched cohort. RESULTS A total of 1705 children with severe TBI were included in the study cohort. The overall in-hospital mortality was 14.3% of patients (n = 243), whereas the mortality of the 273 patients (16%) who underwent invasive ICP monitoring was 11% (n = 30). After adjusting for patient- and hospital-level characteristics, ICP monitoring was associated with lower in-hospital mortality (adjusted OR 0.50; 95% CI 0.30–0.85; p = 0.01). It is possible that patients who were managed with ICP monitoring were selected because of an anticipated favorable or unfavorable outcome. To further address this potential selection bias, the analysis was repeated with the hospital-specific rate of ICP monitoring use as the exposure. The adjusted OR for death of children treated at high ICP–use hospitals was 0.49 compared with those treated at low ICP-use hospitals (95% CI 0.31–0.78; p = 0.003). Variations in ICP monitoring use accounted for 15.9% of the interhospital variation in mortality among children with severe TBI. Similar results were obtained after analyzing the data using propensity score-matching methods. CONCLUSIONS In this observational study, ICP monitoring use was associated with lower hospital mortality at both the patient and hospital levels. However, the contribution of variable ICP monitoring rates to interhospital variation in pediatric TBI mortality was modest.

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Intracranial Pressure during External Ventricular Drainage Weaning Is an Outcome Predictor of Traumatic Brain Injury

BioMed Research International ◽

10.1155/2020/8379134 ◽

2020 ◽

Vol 2020 ◽

pp. 1-7

Author(s):

Jia-cheng Gu ◽

Hong Wu ◽

Xing-zhao Chen ◽

Jun-feng Feng ◽

Guo-yi Gao ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

External Ventricular Drainage ◽

Unfavorable Outcome ◽

Ventricular Drainage ◽

Outcome Group ◽

Significant Difference ◽

The Mean ◽

The Relationship

External ventricular drainage (EVD) is widely used in patients with a traumatic brain injury (TBI). However, the EVD weaning trial protocol varies and insufficient studies focus on the intracranial pressure (ICP) during the weaning trial. We aimed to establish the relationship between ICP during an EVD weaning trial and the outcomes of TBI. We enrolled 37 patients with a TBI with an EVD from July 2018 to September 2019. Among them, 26 were allocated to the favorable outcome group and 11 to the unfavorable outcome group (death, post-traumatic hydrocephalus, persistent vegetative state, and severe disability). Groups were well matched for sex, pupil reactivity, admission Glasgow Coma Scale score, Marshall computed tomography score, modified Fisher score, intraventricular hemorrhage, EVD days, cerebrospinal fluid output before the weaning trial, and the complications. Before and during the weaning trial, we recorded the ICP at 1-hour intervals to calculate the mean ICP, delta ICP, and ICP burden, which was defined as the area under the ICP curve. There were significant between-group differences in the age, surgery types, and intensive care unit days (p=0.045, p=0.028, and p=0.004, respectively). During the weaning trial, 28 (75.7%) patients had an increased ICP. Although there was no significant difference in the mean ICP before and during the weaning trial, the delta ICP was higher in the unfavorable outcome group (p=0.001). Moreover, patients who experienced death and hydrocephalus had a higher ICP burden, which was above 20 mmHg (p=0.016). Receiver operating characteristic analyses demonstrated the predictive ability of these variables (area under the curve AUC=0.818 [p=0.002] for delta ICP and AUC=0.758 [p=0.038] for ICP burden>20 mmHg). ICP elevation is common during EVD weaning trials in patients with TBI. ICP-related parameters, including delta ICP and ICP burden, are significant outcome predictors. There is a need for larger prospective studies to further explore the relationship between ICP during EVD weaning trials and TBI outcomes.

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