TERAPI HIPEROSMOLAR SEBAGAI TATA LAKSANA EDEMA SEREBRI PASCACEDERA KEPALA: LAPORAN KASUS BERBASIS BUKTI

HYPEROSMOLAR THERAPY FOR CEREBRAL EDEMA POST TRAUMATIC BRAIN INJURY: AN EVIDENCE-BASED CASE REPORTABSTRACTMannitol is an agent widely used to treat hyperosmolarity in cases of increased intracranial pressure after acute traumatic brain injury (TBI). Hypertonic saline is an alternative agent in such cases but is still not well-recognized in daily practice. Thus, a literature searching was conducted to see whether mannitol is more effective and safer than hypertonic saline in reducing intracranial pressure in patients with cerebral edema post TBI. The results of literature searching using PubMed, Google Scholar, and Cochrane Database of Systematic Review showed that there is no clear evidence suggesting mannitol is better than hypertonic saline, and vice versa. Therefore, hypertonic saline should be considered as an alternative treatment for hyperosmolarity besides mannitol.Keywords: Cerebral edema, hyperosmolar therapy, hypertonic saline, mannitol, traumatic brain injuryABSTRAKManitol sebagai agen terapi hiperosmolar untuk menurunkan tekanan intrakranial (TIK) pascacedera kepala telah digunakan secara luas. Sementara pilihan lainnya, yaitu larutan salin hipertonik, masih jarang diaplikasikan pada praktik sehari-hari. Oleh karena itu, dilakukan pencarian literatur untuk menilai efektivitas dan keamanan manitol dibandingkan larutan salin hipertonik dalam menurunkan tekanan intrakranial berdasarkan kasus pasien yang mengalami edema serebri pascacedera kepala. Hasil pencarian di PubMed, Google Scholar, dan Cochrane Database of Systematic Review menunjukkan belum ada bukti ilmiah yang secara tegas menyimpulkan manitol lebih efektif dan aman daripada larutan salin hipertonik maupun sebaliknya. Oleh karena itu, larutan salin hipertonik dapat dijadikan alternatif terapi hiperosmolar selain manitol.Kata kunci: Cedera kepala, edema serebri, manitol, salin hipertonik, terapi hiperosmolar

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Hypertonic saline in severe traumatic brain injury: a systematic review and meta-analysis of randomized controlled trials

CJEM ◽

10.1017/cem.2016.12 ◽

2016 ◽

Vol 18 (2) ◽

pp. 112-120 ◽

Cited By ~ 26

Author(s):

Elyse Berger-Pelleiter ◽

Marcel Émond ◽

François Lauzier ◽

Jean-François Shields ◽

Alexis F. Turgeon

Keyword(s):

Systematic Review ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Randomized Controlled Trials ◽

Hypertonic Saline ◽

Severe Traumatic Brain Injury ◽

Controlled Trials ◽

Cochrane Central Register ◽

Randomized Controlled

AbstractObjectivesHypertonic saline solutions are increasingly used to treat increased intracranial pressure following severe traumatic brain injury. However, whether hypertonic saline provides superior management of intracranial pressure and improves outcome is unclear. We thus conducted a systematic review to evaluate the effect of hypertonic saline in patients with severe traumatic brain injury.MethodsTwo researchers independently selected randomized controlled trials studying hypertonic saline in severe traumatic brain injury and collected data using a standardized abstraction form. No language restriction was applied. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and BIOSIS databases. We searched grey literature via OpenGrey and National Technical Information Service databases. We searched the references of included studies and relevant reviews for additional studies.ResultsEleven studies (1,820 patients) were included. Hypertonic saline did not decrease mortality (risk ratio 0.96, 95% confidence interval [CI] 0.83 to 1.11, I2=0%) or improve intracranial pressure control (weighted mean difference −1.25 mm Hg, 95% CI −4.18 to 1.68, I2=78%) as compared to any other solutions. Only one study reported monitoring for adverse events with hypertonic saline, finding no significant differences between comparison groups.ConclusionsWe observed no mortality benefit or effect on the control of intracranial pressure with the use of hypertonic saline when compared to other solutions. Based on the current level of evidence pertaining to mortality or control of intracranial pressure, hypertonic saline could thus not be recommended as a first-line agent for managing patients with severe traumatic brain injury.

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Does Vasopressin Exacerbate Cerebral Edema in Patients with Severe Traumatic Brain Injury?

The American Surgeon ◽

10.1177/000313481808400121 ◽

2018 ◽

Vol 84 (1) ◽

pp. 43-50 ◽

Cited By ~ 4

Author(s):

Casey J. Allen ◽

Ty K. Subhawong ◽

Mena M. Hanna ◽

Lydia Chelala ◽

M. Ross Bullock ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Cerebral Edema ◽

Perfusion Pressure ◽

Single Institution ◽

Lower Plasma ◽

Hyperosmolar Therapy ◽

Ct Attenuation ◽

Total Fluid

Arginine vasopressin (AVP) is often used as an alternative pressor to catecholamines (CATs). However, unlike CATs, AVP is a powerful antidiuretic that could promote edema. We tested the hypothesis that AVP promoted cerebral edema and/or increased requirements for osmotherapy, relative to those who received CATs, for cerebral perfusion pressure (CPP) management after traumatic brain injury (TBI). This is a retrospective review of 286 consecutive TBI patients with intracranial pressure monitoring at a single institution from September 2008 to January 2015. Cerebral edema was quantitated using CT attenuation in prespecified areas of gray and white matter. Results: To maintain CPP >60 mm Hg, 205 patients required no vasopressors, 41 received a single CAT, 12 received AVP, and 28 required both. Those who required no pressors were generally less injured; required less hyperosmolar therapy and less total fluid; and had lower plasma Na, lower intracranial pressure, less edema, and lower mortality (all P < 0.05). Edema; daily mean, minimum, and maximum Na levels; and mortality were similar with AVP versus CATs, but the daily requirement of mannitol and 3 per cent NaCl were reduced by 45 and 35 per cent (both P < 0.05). In patients with TBI who required CPP therapy, AVP reduced the requirements for hyperosmolar therapy and did not delay resolution or increase cerebral edema compared with CATs.

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Faculty Opinions recommendation of Assessing the impact of 3% hypertonic saline hyperosmolar therapy on intubated children with isolated traumatic brain injury by cerebral oximetry in a pediatric emergency setting.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.737479813.793583750 ◽

2021 ◽

Author(s):

Saskia de Wildt ◽

Gerald Jaspers

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Hypertonic Saline ◽

Pediatric Emergency ◽

Cerebral Oximetry ◽

Emergency Setting ◽

Hyperosmolar Therapy ◽

The Impact

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Hypertonic saline or mannitol for treating elevated intracranial pressure in traumatic brain injury: a meta-analysis of randomized controlled trials

Neurosurgical Review ◽

10.1007/s10143-018-0991-8 ◽

2018 ◽

Vol 42 (2) ◽

pp. 499-509 ◽

Cited By ~ 21

Author(s):

Jiajie Gu ◽

Haoping Huang ◽

Yuejun Huang ◽

Haitao Sun ◽

Hongwu Xu

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Randomized Controlled Trials ◽

Hypertonic Saline ◽

Meta Analysis ◽

Controlled Trials ◽

Elevated Intracranial Pressure ◽

Randomized Controlled

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

Journal of Neurosurgery Pediatrics ◽

10.3171/2021.6.peds21143 ◽

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.

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

Pediatric Critical Care Medicine ◽

10.1097/pcc.0000000000001867 ◽

2019 ◽

Vol 20 (5) ◽

pp. 466-473 ◽

Cited By ~ 6

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

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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

Journal of the Intensive Care Society ◽

10.1177/1751143720901690 ◽

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.

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

QJM ◽

10.1093/qjmed/hcaa055.006 ◽

2020 ◽

Vol 113 (Supplement_1) ◽

Author(s):

A K Ali ◽

A E Abdelbar ◽

A R Farghaly ◽

M K A Uthman

Keyword(s):

Systematic Review ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

English Literature ◽

Intracranial Pressure Monitoring ◽

Occurrence Rate ◽

Icp Monitoring ◽

Pressure Monitoring ◽

Mortality And Morbidity

Abstract Background Traumatic brain injury (TBI) is among the most important public health problems associated with high healthcare and social burden and significant mortality and morbidity. Overall low income countries have the highest TBI associated mortality and morbidity. Aim of the Work Some studies have demonstrated that intracranial pressure (ICP) monitoring reduces the mortality of traumatic brain injury (TBI). But other studies have shown that ICP monitoring is associated with increased mortality. Patients and Methods Systematic review of Published English literature from 2000 to 2017. Using appropriate combinations of MeSH terms and key words, including intracranial pressure, intracranial hypertension, ICP monitor, intracranial pressure monitoring, TBI traumatic brain injury, and craniocerebral trauma. Brain Trauma Foundation guidelines, mortality. We performed this relatively wide search to include the maximum number of relevant patients. Results In total, 2552 studies were identified and screened for retrieval using the strategy described above. After careening the title and abstract, 1968 studies were excluded and 554 were retrieved and subjected to detailed evaluations. Based on the inclusion and exclusion criteria, 527 of those studies were excluded, and thus 27 studies were included in the systematic review. All included studies were published, peer-previewed papers. Conclusion ICP monitoring may play a role in decreasing the rate of electrolyte disturbances, rate of renal failure, and increasing favorable functional outcome. However, there was no significant effect for reducing the risk of hospital mortality, lowering occurrence rate of pulmonary infection, use of mechanical ventilation and duration of hospital stays. RCTs with larger sample size are necessary to further support the current results.

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