Effects of hypertonic saline on intracranial pressure and cerebral autoregulation in pediatric traumatic brain injury

2021 ◽  
pp. 1-7
Author(s):  
Julian Zipfel ◽  
Juliane Engel ◽  
Konstantin Hockel ◽  
Ellen Heimberg ◽  
Martin U. Schuhmann ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Hypertonic Saline ◽  
Pediatric Patients ◽  
Injury Severity ◽  
Primary Outcome Measure ◽  
Favorable Outcome ◽  
Outcome Group ◽  
Significant Difference

OBJECTIVE Hypertonic saline (HTS) is commonly used in children to lower intracranial pressure (ICP) after severe traumatic brain injury (sTBI). While ICP and cerebral perfusion pressure (CPP) correlate moderately to TBI outcome, indices of cerebrovascular autoregulation enhance the correlation of neuromonitoring data to neurological outcome. In this study, the authors sought to investigate the effect of HTS administration on ICP, CPP, and autoregulation in pediatric patients with sTBI. METHODS Twenty-eight pediatric patients with sTBI who were intubated and sedated were included. Blood pressure and ICP were actively managed according to the autoregulation index PRx (pressure relativity index to determine and maintain an optimal CPP [CPPopt]). In cases in which ICP was continuously > 20 mm Hg despite all other measures to decrease it, an infusion of 3% HTS was administered. The monitoring data of the first 6 hours after HTS administration were analyzed. The Glasgow Outcome Scale (GOS) score at the 3-month follow-up was used as the primary outcome measure, and patients were dichotomized into favorable (GOS score 4 or 5) and unfavorable (GOS score 1–3) groups. RESULTS The mean dose of HTS was 40 ml 3% NaCl. No significant difference in ICP and PRx was seen between groups at the HTS administration. ICP was lowered significantly in all children, with the effect lasting as long as 6 hours. The lowering of ICP was significantly greater and longer in children with a favorable outcome (p < 0.001); only this group showed significant improvement of autoregulatory capacity (p = 0.048). A newly established HTS response index clearly separated the outcome groups. CONCLUSIONS HTS significantly lowered ICP in all children after sTBI. This effect was significantly greater and longer-lasting in children with a favorable outcome. Moreover, HTS administration restored disturbed autoregulation only in the favorable outcome group. This highlights the role of a “rescuable” autoregulation regarding outcome, which might be a possible indicator of injury severity. The effect of HTS on autoregulation and other possible mechanisms should be further investigated.

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

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.

scholarly journals Traumatic Brain Injury: Bolus Versus Continuous Infusion of 3% Hypertonic Saline

2016 ◽  
Vol 101 (7-8) ◽  
pp. 361-366
Author(s):  
David Parizh ◽  
Ilya Parizh ◽  
Caitlyn Kuwata ◽  
Galina Glinik ◽  
Anthony Kopatsis
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Continuous Infusion ◽  
Hypertonic Saline ◽  
Serum Sodium ◽  
Increased Intracranial Pressure ◽  
Significant Difference ◽  
Route Of Delivery ◽  
Neurosurgical Intervention

Hypertonic saline (HTS) is used as an adjunct in the conservative management of increased intracranial pressure; however, the ideal concentration or route of delivery is unknown. Our objective was to assess whether there is a difference in route of delivery, bolus versus infusion, of 2% versus 3% HTS in patients with traumatic brain injury. The study comprises a retrospective analysis of all patients who sustained traumatic brain injury resulting in increased intracranial pressure that required HTS from January 2012 to December 2014. We examined time to therapeutic serum sodium concentration greater or equal to 150 mEq; incidence of ventriculostomy placement and neurosurgical intervention for refractory intracanial hypertension; and disability burden among the different infusates and route of delivery. A total of 169 patients received either 2% or 3% HTS, given as a bolus or continuous infusion. Patients had an average age of 61.4 years; 100 patients (59.2%) were male and 69 (40.8%) were female; 62 patients were taking either an antiplatelet or anticoagulant agent. Infusion of 3% saline was associated with the shortest interval to reaching a therapeutic level at 1.61 days (P = 0.024). There was no statistically significant difference between placement of a ventriculostomy among the bolus and infusion groups of 3% normal saline (NS) (P = 0.475). However, neurosurgical intervention was less prevalent in those receiving 3% infusion (P = 0.013). Infusion of 3% HTS was associated with a more rapid increase in serum sodium to therapeutic levels. Neurosurgical intervention for refractory hypertension was less prevalent in the 3% NS infusion group.

Decompressive Craniectomy in Children

Neurosurgery ◽  
2011 ◽  
Vol 70 (4) ◽  
pp. 881-889 ◽  
Author(s):  
Erdem Güresir ◽  
Patrick Schuss ◽  
Volker Seifert ◽  
Hartmut Vatter
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Decompressive Craniectomy ◽  
Pediatric Patients ◽  
Pediatric Population ◽  
Favorable Outcome ◽  
Brain Swelling ◽  
Current Series ◽  
Cerebral Herniation

Abstract BACKGROUND: Decompressive craniectomy (DC) is performed as a life-saving procedure in patients with intractably increased intracranial pressure after traumatic brain injury, bleeding, cerebral infarction, or brain swelling of other causes. However, the application of DC is as controversial in the pediatric population as it is in adults. OBJECTIVE: To find factors influencing the outcome in pediatric patients who underwent DC because of sustained high intracranial pressure. METHODS: Between April 2000 and December 2009, 34 pediatric patients (age 0-18 years) underwent DC. Patients were stratified according to the indication for DC. Outcome was assessed according to the modified Rankin Scale score at 6 months. MEDLINE was searched for published studies or reports of DC in pediatric patients to gain a larger population. Two reviewers independently extracted data. RESULTS: Literature data, including the current series, revealed a total of 172 pediatric patients. Overall, a favorable outcome was achieved in 106 of 172 patients (62%). A favorable outcome was achieved in 25 of 36 patients without traumatic brain injury vs 81 of 136 patients with traumatic brain injury (69% vs 60%). Patients without signs of cerebral herniation had a better outcome than patients with unilateral or bilateral dilated pupils (73% vs 60% vs 45%, respectively). CONCLUSION: The current data indicate that DC in children with traumatic or nontraumatic brain swelling might be warranted, regardless of the underlying cause. Despite mydriasis, a favorable outcome might be achieved in a significant number of pediatric patients. Nevertheless, careful individual decision making is needed for each patient, especially when signs of cerebral herniation have persisted for a long time.

scholarly journals Effect of Continuous Hypertonic Saline Infusion on Clinical Outcomes in Patients with Traumatic Brain Injury: A Retrospective Causal Analysis

2021 ◽  
Author(s):  
Chi Peng ◽  
Fan Yang ◽  
Chenxu Zhang ◽  
Lulong Bo ◽  
Jian Yu ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Intensive Care ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Clinical Outcomes ◽  
Hypertonic Saline ◽  
Cox Model ◽  
Electrolyte Imbalance ◽  
Research Database ◽  
Significant Difference

Abstract Purpose: Intracranial pressure (ICP) control has long been recognized as an important requirement for traumatic brain injury (TBI) patients. Nevertheless, the long-term effect of hypertonic saline (HTS) remains unknown. The aim of this study was to elucidate the effect on clinical outcomes in TBI patients admitted to intensive care unit (ICU) settings.Methods: We retrospectively identified moderate to severe TBI patients from two public databases named Medical Information Mart for the Intensive Care (MIMIC)-IV and eICU Collaborative Research Database (eICU-CRD). A marginal structural Cox model (MSCM) was used, with time-dependent variates designed to reflect exposure over time during the ICU stay. A trajectory modeling, based on intracranial pressure evolution pattern, allowed identification of subgroups. Results: Overall, in our cohort of 1955 eligible patients, 130 (6.65%) received HTS. MSCM indicated that the HTS was significantly associated with better Glasgow coma score [(GCS): hazard ratio (HR) 1.19, 95% confidence interval (95% CI) 1.01-1.40, p = 0.041], higher infection complications [eg. urinary tract infection (HR 1.88, 95% CI 1.26-2.81, p = 0.002)], and increased ICU LOS (HR 2.02, 95% CI 1.71-2.40, p < 0.001). A protective effect from GCS by the HTS was found in the subgroup with medium and low ICP. Conclusion: Our study revealed no significant difference in the all-cause mortality rates between patients receiving HTS or not. Increased occurrence rates of infection and electrolyte imbalance were inevitable outcomes caused by continuous HTS infusion. Although the study suggested the slight beneficial effects including better neurological outcome, the results warrant further validation.

One-year costs of intensive care in pediatric patients with traumatic brain injury

2021 ◽  
Vol 27 (1) ◽  
pp. 79-86
Author(s):  
Era D. Mikkonen ◽  
Markus B. Skrifvars ◽  
Matti Reinikainen ◽  
Stepani Bendel ◽  
Ruut Laitio ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Intensive Care ◽  
Brain Injury ◽  
Social Security ◽  
Functional Outcome ◽  
Injury Severity ◽  
Pediatric Population ◽  
Favorable Outcome ◽  
Index Hospitalization ◽  
Pediatric Tbi

OBJECTIVETraumatic brain injury (TBI) is a major cause of death and disability in the pediatric population. The authors assessed 1-year costs of intensive care in pediatric TBI patients.METHODSIn this retrospective multicenter cohort study of four academic ICUs in Finland, the authors used the Finnish Intensive Care Consortium database to identify children aged 0–17 years treated for TBI in ICUs between 2003 and 2013. The authors reviewed all patient health records and head CT scans for admission, treatment, and follow-up data. Patient outcomes included functional outcome (favorable outcome defined as a Glasgow Outcome Scale score of 4–5) and death within 6 months. Costs included those for the index hospitalization, rehabilitation, and social security up to 1 year after injury. To assess costs, the authors calculated the effective cost per favorable outcome (ECPFO).RESULTSIn total, 293 patients were included, of whom 61% had moderate to severe TBI (Glasgow Coma Scale [GCS] score 3–12) and 40% were ≥ 13 years of age. Of all patients, 82% had a favorable outcome and 9% died within 6 months of injury. The mean cost per patient was €48,719 ($54,557) (95% CI €41,326–€56,112). The index hospitalization accounted for 66%, rehabilitation costs for 27%, and social security costs for 7% of total healthcare costs. The ECPFO was €59,727 ($66,884) (95% CI €52,335–€67,120). A higher ECPFO was observed among patients with clinical and treatment-related variables indicative of parenchymal swelling and high intracranial pressure. Lower ECPFO was observed among patients with higher admission GCS scores and those who had epidural hematomas.CONCLUSIONSGreater injury severity increases ECPFO and is associated with higher postdischarge costs in pediatric TBI patients. In this pediatric cohort, over two-thirds of all resources were spent on patients with favorable functional outcome, indicating appropriate resource allocation.

scholarly journals Behavioral Pain Indicators in Patients with Traumatic Brain Injury Admitted to an Intensive Care Unit

2018 ◽  
Vol 7 (4) ◽  
pp. 197-203 ◽  
Author(s):  
Roghieh Nazari ◽  
Saeed Pahlevan Sharif ◽  
Kelly A Allen ◽  
Hamid Sharif Nia ◽  
Bit-Lian Yee ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Traumatic Brain Injury ◽  
Intensive Care ◽  
Brain Injury ◽  
Injury Severity ◽  
Repeated Measure ◽  
Neck Stiffness ◽  
Significant Difference ◽  
Eye Opening ◽  
Different Levels

Introduction: A consistent approach to pain assessment for patients admitted to intensive care unit (ICU) is a major difficulty for health practitioners due to some patients’ inability, to express their pain verbally. This study aimed to assess pain behaviors (PBs) in traumatic brain injury (TBI) patients at different levels of consciousness. Methods: This study used a repeated-measure, within-subject design with 35 patients admitted to an ICU. The data were collected through observations of nociceptive and non-nociceptive procedures, which were recorded through a 47-item behavior-rating checklist. The analyses were performed by SPSS ver.13 software. Results: The most frequently observed PBs during nociceptive procedures were facial expression levator contractions (65.7%), sudden eye openings (34.3%), frowning (31.4%), lip changes (31.4%), clear movement of extremities (57.1%), neck stiffness (42.9%), sighing (31.4%), and moaning (31.4%). The number of PBs exhibited by participants during nociceptive procedures was significantly higher than those observed before and 15 minutes after the procedures. Also, the number of exhibited PBs in patients during nociceptive procedures was significantly greater than that of exhibited PBs during the non-nociceptive procedure. The results showed a significant difference between different levels of consciousness and also between the numbers of exhibited PBs in participants with different levels of traumatic brain injury severity. Conclusion: The present study showed that most of the behaviors that have been observed during painful stimulation in patients with traumatic brain injury included facial expressions, sudden eye opening, frowning, lip changes, clear movements of extremities, neck stiffness, and sighing or moaning.

23.4% Hypertonic Saline and Intracranial Pressure in Severe Traumatic Brain Injury Among Children

2019 ◽  
Vol 20 (5) ◽  
pp. 466-473 ◽  
Author(s):  
Andrew G. Wu ◽  
Uzma Samadani ◽  
Tina M. Slusher ◽  
Lei Zhang ◽  
Andrew W. Kiragu
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Hypertonic Saline ◽  
Severe Traumatic Brain Injury

scholarly journals Sugar or salt (“SOS”): A protocol for a UK multicentre randomised trial of mannitol and hypertonic saline in severe traumatic brain injury and intracranial hypertension

2020 ◽  
pp. 175114372090169
Author(s):  
MJ Rowland ◽  
T Veenith ◽  
C Scomparin ◽  
MH Wilson ◽  
PJ Hutchinson ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Cost Effectiveness ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Hypertonic Saline ◽  
Severe Traumatic Brain Injury ◽  
Randomised Trial ◽  
Pragmatic Trial ◽  
Open Label ◽  
The Impact

Hyperosmolar solutions are widely used to treat raised intracranial pressure following severe traumatic brain injury. Although mannitol has historically been the most frequently administered, hypertonic saline solutions are increasingly being used. However, definitive evidence regarding their comparative effectiveness is lacking. The Sugar or Salt Trial is a UK randomised, allocation concealed open label multicentre pragmatic trial designed to determine the clinical and cost-effectiveness of hypertonic saline compared with mannitol in the management of patients with severe traumatic brain injury. Patients requiring intensive care unit admission and intracranial pressure monitoring post-traumatic brain injury will be allocated at random to receive equi-osmolar boluses of either mannitol or hypertonic saline following failure of routine first-line measures to control intracranial pressure. The primary outcome for the study will be the Extended Glasgow Outcome Scale assessed at six months after randomisation. Results will inform current clinical practice in the routine use of hyperosmolar therapy as well as assess the impact of potential side effects. Pre-planned longer term clinical and cost effectiveness analyses will further inform the use of these treatments.

scholarly journals Advanced Neuromonitoring and Imaging in Pediatric Traumatic Brain Injury

2012 ◽  
Vol 2012 ◽  
pp. 1-11 ◽  
Author(s):  
Stuart H. Friess ◽  
Todd J. Kilbaugh ◽  
Jimmy W. Huh
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Early Detection ◽  
Pediatric Patients ◽  
Vital Signs ◽  
Pediatric Traumatic Brain Injury ◽  
Pressure Monitoring ◽  
Biomarker Analysis ◽  
Insight Into

While the cornerstone of monitoring following severe pediatric traumatic brain injury is serial neurologic examinations, vital signs, and intracranial pressure monitoring, additional techniques may provide useful insight into early detection of evolving brain injury. This paper provides an overview of recent advances in neuromonitoring, neuroimaging, and biomarker analysis of pediatric patients following traumatic brain injury.

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