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Indian Journal of Neurotrauma 2007; 04(02): 101-107
DOI: 10.1016/S0973-0508(07)80023-2
Original Article
Thieme Medical and Scientific Publishers Private Ltd.

Efficacy of different hypertonic solutes in the treatment of refractory intracranial hypertension in severe head injury patients: A comparative study of 2ml/kg 7.5% hypertonic saline and 2ml/kg 20% mannitol

Nilay Chatterjee
*   Department of Critical Care, The Calcutta Medical Research Institute, 7/2 D.H. Road, Kolkata 700027
,
Arpan Chaudhury
,
Sujoy Mukherjee
,
Gouri Kumar Prusty
*   Department of Critical Care, The Calcutta Medical Research Institute, 7/2 D.H. Road, Kolkata 700027
,
Tapas Chattopadhyay
,
Subhasis Saha
**   Department of Pediatric Surgery, The Calcutta Medical Research Institute, 7/2 D.H. Road, Kolkata 700027
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Publication Date:
05 April 2017 (online)

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Abstract

A prospective, randomized study to evaluate the clinical benefit of increasing the osmotic load of the hypertonic solution administered for the treatment of refractory intracranial hypertension episodes in patients with severe head injury. 25 patients with severe head injury and persistent coma, admitted in a Neurocritical Care Unit of a Tertiary Care Hospital, who required infusions of osmotic agents to treat episodes of intracranial hypertension resistant to well defined standard modes of therapy were randomly allocated to one of the two groups to receive isovolume infusions of either 7.5% hypertonic saline solution; HS [2400 mOsm/kg H2O] or 20% mannitol [1160 mOsm/kg of H2O] given 2ml/kg of either solution, i.e. 331.5 +/− 35.4 mOsm of hypertonic saline or 174.2 +/− 18 mOsm of mannitol per infusion. The variables recorded in the study were the duration and number of episodes of intracranial hypertension per day during the study period, which was stopped after the last episode of intracranial hypertension was recorded from intracranial pressure recording or after the allocated treatment failure. Patients of HS group were monitored for 7 +/− 6 days and those in the mannitol group for 8 +/− 5 days [p=NS]. The rate of failure for each treatment was also evaluated which was defined as the persistence of intracranial hypertension despite the two successive infusions of the same osmotic agent. The mean number of osmotic solute infusions was 3.4 +/− 4.5 in the HS group and 3.8 +/− 5.1 in mannitol group p=NS]. The mean number [7.1+/-2.9 vs. 14.6+/−3.4] of episodes of intracranial hypertension per day and the duration of such episode [62.6+/−28.1 vs. 93.4+/−37.2 min] was also significantly lower in the HS group [p<0.05]. The numbers of treatment failures were significantly lower in HS group: 1 out of 14 patients vs. 6 out of 11 patients [p<0.01]. In this study we have found that in patients with severe head injury requiring treatment with hypertonic solute for refractory intracranial hypertension, 2ml/kg body weight of 7.5% HS [356 +/− 14 mOsm] was more effective than giving 2ml/kg 20% mannitol [178 +/− 11mOsm]. Within the limitations of present study, the collected data suggest that giving 2ml/kg HS solution is an effective and safe initial treatment for intracranial hypertension episodes in head injury patients when there is indication of osmotherapy.

Keywords

Intracranial Hypertension - Mannitol - Hypertonic Saline - Head Injury
 

  • References

  • 1 Archer DP, Freymond D, Ravussin P. Utilisation du mannitol en neuroanesthesie et, neuroreanimation. Ann Fr Anesth Reanim 14 1995; 77-82
    CrossrefPubMedSearch in Google Scholar
  • 2 Fisher B, Thomas D, Peterson B. Hypertonic saline lowers raised intracranial pressure in children after head trauma. J Neurosurg Anesthesiol 04 1992; 4-10
    CrossrefPubMedSearch in Google Scholar
  • 3 Meier-Hellmann A, Reinhart K, Bloos F. Hypertonic solutions in emergency medicine. In: Vincent JL. (Ed). Yearbook of Intensive Care and Emergency Medicine. 1995. Springer-Verlag; Berlin: 935-944
    Search in Google Scholar
  • 4 Worthley LI, Cooper DJ, Jones N. Treatment of resistant intracranial hypertension with hypertonic saline: Report of two cases. J Neurosurg 68 1988; 478-481
    CrossrefPubMedSearch in Google Scholar
  • 5 Oken DE. Renal and extrarenal considerations in high-dose mannitol therapy. Ren Fail 16 1994; 147-159
    CrossrefPubMedSearch in Google Scholar
  • 6 Bullock R. Mannitol and other diuretics in severe neurotrauma. New Horiz 03 1995; 448-452
    PubMedSearch in Google Scholar
  • 7 Arai T, Tsukahara I, Nitta K. et al Effects of mannitol on cerebral circulation after transient complete cerebral ischemia in dogs. Crit Care Med 14 1986; 634-637
    CrossrefPubMedSearch in Google Scholar
  • 8 Garcia-Sola R, Pulido P, Capilla P. The immediate and long-term effects of mannitol and glycerol: A comparative experimental study. Acta Neurochir (Wien) 109 1991; 114-121
    CrossrefPubMedSearch in Google Scholar
  • 9 Kofke WA. Mannitol: Potential for rebound intracranial hypertension?. J Neurosurg Anesthesiol 05 1993; 1-3
    CrossrefPubMedSearch in Google Scholar
  • 10 Polderman KH, van de Kraats G, Dixon JM. et al Increases in spinal fluid osmolarity induced by mannitol. Crit Care Med 31 2003; 584-590
    CrossrefPubMedSearch in Google Scholar
  • 11 Vialet R, Albanese J, Thomachot L. et al Isovolume hypertonic solutes (sodium chloride or mannitol) in the treatment of refractory posttraumatic intracranial hypertension: 2 mL/kg 7.5% saline is more effective than 2 mL/kg 20% mannitol. Crit Care Med 31 2003; 1683-1687
    CrossrefPubMedSearch in Google Scholar
  • 12 Battison C, Andrews PJ, Graham C. et al Randomized, controlled trial on the effect of a 20% mannitol solution and a 7.5% saline/ 6% dextran solution on increased intracranial pressure after brain injury. Crit Care Med 33 2005; 196-202
    CrossrefPubMedSearch in Google Scholar
  • 13 De Vivo P, Del Gaudio A, Ciritella P. et al Hypertonic saline solution: A safe alternative to mannitol 18% in neurosurgery. Minerva Anestesiol 67 2001; 603-611
    PubMedSearch in Google Scholar
  • 14 Schwarz S, Schwab S, Bertram M. et al Effects of hypertonic saline hydroxyethyl starch solution and mannitol in patients with increased intracranial pressure after stroke. Stroke 29 1998; 1550-1555
    CrossrefPubMedSearch in Google Scholar
  • 15 Zornow MH. Hypertonic saline as a safe and efficacious treatment of intracranial hypertension. J Neurosurg Anesthesiol 08 1996; 175-177
    CrossrefPubMedSearch in Google Scholar
  • 16 Weinstabl C, Mayer N, German P. et al Hypertonic, hyperoncotic hydroxyethyl starch decreases intracranial pressure following neurotrauma. Anesthesiology 75 1991; A201
    CrossrefPubMedSearch in Google Scholar
  • 17 Vassar MJ, Fischer RP, O’Brien PE. et al A multicenter trial for resuscitation of injured patients with 7.5% sodium chloride. Arch Surg 128 1993; 1003-1013
    CrossrefPubMedSearch in Google Scholar
  • 18 Berger S, Schurer L, Hartl R. et al 7.2% NaCl/10% dextran 60 versus 20% mannitol for treatment of intracranial hypertension. Acta Neurochir Suppl (Wien) 60 1994; 494-498
    PubMedSearch in Google Scholar
  • 19 Freshman SP, Battistella FD, Matteuci M. et al Hypertonic saline (7.5%) versus mannitol: A comparison for treatment of acute injury. J Trauma 35 1993; 344-348
    CrossrefPubMedSearch in Google Scholar
  • 20 Scheller M, Zornov M, Oh Y. A comparison of the cerebral and hemodynamic effects of mannitol and hypertonic saline in a rabbit model of acute cryogenic brain injury. J Neurosurg Anesthesiol 03 1991; 291-296
    CrossrefPubMedSearch in Google Scholar
  • 21 Gunnar W, Jonasson O, Merlotti G. et al Head injury and hemorrhagic shock: Studies of the blood brain-barrier and intracranial pressure after resuscitation with normal saline solution, 3% saline solution, and dextran- 40. Surgery 103 1988; 398-407
    PubMedSearch in Google Scholar
  • 22 Wisner DH, Schuster L, Quinn C. Hypertonic saline resuscitation of head injury: Effects on cerebral water content. J Trauma 30 1990; 75-78
    PubMedSearch in Google Scholar
  • 23 Shackford SR, Zhuang J, Schmoker J. Intravenous fluid tonicity: Effect on intracranial pressure, cerebral blood flow, and cerebral oxygen delivery in focal brain injury. J Neurosurg 76 1992; 91-98
    CrossrefPubMedSearch in Google Scholar
  • 24 Winkler SR, Munoz Ruiz L. Mechanism of action of mannitol. Surg Neurol 43 1995; 59
    PubMedSearch in Google Scholar
  • 25 Wise BL, Chater N. The value of hypertonic mannitol solution in decreasing brain mass and lowering cerebrospinal fluid pressure. J Neurosurg 19 1962; 1038-1043
    CrossrefPubMedSearch in Google Scholar
  • 26 Barry KG, Berman AR. Mannitol infusion. Part III. The acute effects of the intravenous infusion of mannitol on blood plasma volume. N Engl J Med 264 1961; 1085-1088
    CrossrefPubMedSearch in Google Scholar
  • 27 Dominguez R, Corcoran AC, Page IH. Mannitol. Kinetics of distribution, excretion, and utilization in human beings. J Lab Clin Med 32 1947; 1192-1202
    PubMedSearch in Google Scholar
  • 28 Coté CJ, Greenhow DE, Marshall BE. The hypotensive response to rapid intravenous administration of hypertonic solutions in man and in rabbit. Anesthesiology 47 1979; 28-30
    PubMedSearch in Google Scholar
  • 29 Cottrel JE, Robustelli A, Post K. et al Furosemide and mannitol induced changes in intracranial pressure and serum osmolality and electrolytes. Anesthesiology 47 1977; 28-30
    CrossrefPubMedSearch in Google Scholar
  • 30 Miller JD, Piper IR, Dearden NM. Management of intracranial hypertension in head injury: Matching treatment with cause. Acta Neurochir Suppl (Wien) 57 1993; 152-159
    PubMedSearch in Google Scholar
  • 31 Fortune JB, Feustel PJ, Graca L. et al Effect of hyperventilation, mannitol, and ventriculostomy drainage on cerebral blood flow after blood injury. J Trauma 39 1995; 1091-1097
    CrossrefPubMedSearch in Google Scholar
  • 32 Kirkpatrick P, Smielewski P, Piechnik S. et al Early effects of mannitol in patients with head injuries assessed using bedside multimodality monitoring. Neurosurgery 39 1996; 714-720
    CrossrefPubMedSearch in Google Scholar
  • 33 Hartwell RC, Sutton LN. Mannitol, intracranial pressure, and vasogenic edema. Neurosurgery 32 1993; 444-450
    CrossrefPubMedSearch in Google Scholar
  • 34 Schell RM, Applegate II RL, Cole DJ. Salt, starch, and water on the brain. J Neurosurg Anesthesiol 08 1996; 178-182
    CrossrefPubMedSearch in Google Scholar
  • 35 Velasco IT, Pointieri V, Rocha e Silva M. et al Hyperosmotic NaCl and severe hemorrhagic shock. Am J Physiol 222 1980; 1406-1410
    PubMedSearch in Google Scholar
  • 36 Gemma M, Cozzi S, Tommasino C. et al 7.5% hypertonic saline versus 20% mannitol during elective neurosurgical supratentorial procedures. J Neurosurg Anesthesiol 09 1997; 329-334
    CrossrefPubMedSearch in Google Scholar
  • 37 Gunnar Bentsen, Harald Breivik, Tryggve Lunder. et al Hypertonic saline (7.2%) in 6% hydroxyethyl starch reduces intracranial pressure and improves hemodynamics in a placebo-controlled study involving stable patients with subarachnoid hemorrhage. Crit Care Med 34 2006; 2912-2917
    CrossrefPubMedSearch in Google Scholar
  • 38 Trachtman H. Cell volume regulation. A review of cerebral adaptation mechanisms and implications for clinical treatment of osmolal disturbances (Part II). Pediatr Nephrol 1992; 104-112
    PubMedSearch in Google Scholar
  • 39 Arieff AI, Guisado R. Effects on the central nervous system of hypernatremic and hyponatremic states. Kidney Int 10 1976; 104-116
    CrossrefPubMedSearch in Google Scholar
  • 40 Meier-Hellmann A, Hanneman L, Messmer K. et al Treatment of therapy-resistant intracranial pressure by application of hypertonic saline (7.5%). Eur Surg Res 22 1990; 303-307
    PubMedSearch in Google Scholar
  • 41 Larsson A, Asgeirson B, Grände PO. Treatment of post-traumatic brain edema. In: Vincent JL. (Ed). Yearbook of Intensive Care and Emergency Medicine. 1995. Springer-Verlag; Berlin: 866-874
    Search in Google Scholar
  • 42 Arieff AI, Ayus JC. Pathogenesis and management of hypernatremia. Curr Opin Crit Care 02 1996; 418-423
    CrossrefPubMedSearch in Google Scholar