Hypertonic Saline Bests Mannitol For Traumatic Brain Injury In Children: JAMA

The most commonly used hypertonic solutions for the treatment of elevated ICP are mannitol and hypertonic saline (HTS). However, data are limited on the most effective doses of these agents, and debate remains ongoing over which hypertonic solution is superior. In the pediatric population, HTS (3%) is a level 2 recommendation in the recent guidelines, but this recommendation is based on studies with few patients. Therefore, Dr Patrick M. Kochanek and his team conducted a study to characterize the current use of hyperosmolar agents in pediatric severe traumatic brain injury and assess whether HTS or mannitol is associated with greater decreases in ICP and/or increases in CPP.

In this observational comparative effectiveness analysis, the researchers used data from the Approaches and Decisions for Acute Pediatric TBI Trial (ADAPT) and assessed 1000 children among which 787 children received some form of hyperosmolar therapy during the ICP-directed phase of care, with 518 receiving a bolus. The researchers compared the effect of boluses of HTS and mannitol. They collected data on ICP and CPP before and after medication administration.

Key findings of the study:

• Upon analysis, the researchers found that the bolus HTS decrease ICP and increase CPP (mean [SD] ICP, 1.03 [6.77] mm Hg; mean [SD] CPP, 1.25 [12.47] mm Hg), whereas mannitol increase CPP (mean [SD] CPP, 1.20 [11.43] mm Hg).
• They also found HTS was associated with a greater reduction in ICP compared with mannitol (unadjusted β, −0.85), but observed no association after adjustments (adjusted β, −0.5). They also observed no difference in CPP.
• However, when ICP was greater than 20 mm Hg, greater than 25 mm Hg, or greater than 30 mm Hg, they found that the HTS outperformed mannitol for each threshold in ICP reduction (>20 mm Hg: unadjusted β, −2.51; >25 mm Hg: unadjusted β, −3.88; >30 mm Hg: unadjusted β, −4.07).
• They noted that the results remained significant for ICP greater than 25 mm Hg in adjusted analysis.

The authors concluded, "In this comparative effectiveness research study, bolus HTS was associated with lower ICP and higher CPP, whereas mannitol was associated only with higher CPP. After adjustment for confounders, both therapies showed no association with ICP and CPP. During ICP crises, HTS was associated with better performance than mannitol."

For further information:

DOI:10.1001/jamanetworkopen.2022.0891

Keywords:

Hyperosmolar therapies, Mannitol, 3% hypertonic saline, intracranial pressure,cerebral perfusion pressure, Severe traumatic brain injury, Traumatic brain injury in children, TBI, ADAPT trial, JAMA Network Open.