Anestéziológia a intenzívna medicína 1/2023

Osmotherapy of traumatic brain injury in the ICU – a comparison of the effect of hypertonic NaCl and mannitol on the resulting condition of the patients

Background: Osmotherapy (hyperosmolar therapy) is one of the conservative treatment options for traumatic and non-traumatic cerebral edema. Mannitol has been considered the gold standard since the 1960s. A number of works in the current period have confirmed the high effectiveness of hypertonic NaCl in this indication. When comparing equiosmolar amounts of hypertonic NaCl and mannitol, it was found that hypertonic NaCl reduces increased intracranial pressure more significantly than mannitol and for a longer period of time. The question of the mortality benefit for patients with brain edema treated with hypertonic NaCl remains open, the works published so far have been small in scope and their metaanalyses have not brought conclusions that would confirm that hypertonic NaCl reduces mortality or improves the neurological clinical outcome. Objective: The primary objective was to assess the effect of hypertonic NaCl on patient mortality at discharge from ICU. The secondary objective is to determine whether the administration of hypertonic NaCl brings a benefit in terms of improving the neurological outcome assessed by the Glasgow outcome score-extended upon ICU treatment cessation. Methods: In a prospective study with a historical control group, in which a total of 151 patients hospitalized at OAIM with moderate to severe brain injury were included, we compared the effect of continuously administered 10% NaCl versus mannitol on reducing mortality and improving the neurological outcome of patients with post-traumatic brain edema. The statistical significance of the observed parameters was determined by the chi-square test. Results: 67 patients with an average age of 53.6 years, 12 women and 55 men, were included in the hypertonic NaCl (HTS) group. 84 patients with an average age of 50.9 years were included in the mannitol control group, of which 67 were men and 17 were women. In the group with HTS, death from OAIM occurred in 17.9% of cases and in the mannitol group in 13.1% (due to the size of the groups, the difference in mortality did not reach the level of statistical significance, p=0.4133). With adverse neurological status assessed as GOS-E 2, 19.4% in the HTS group and 20.2% in the mannitol-treated group were transferred from OAIM (no statistically significant difference, p=0.8983), GOS-E 3 29.9 % vs. 16.7% (p=0.0540), GOS-E 4 22.4 vs. 38.1% (p=0.0335) and GOS-E 5 3% vs. 2.4% (p=0.8183). Conclusion: Patients hospitalized in ICU with moderate to severe traumatic brain injury treated with continuous infusion of 10% NaCl do not show a significant difference in mortality and neurological outcome assessed by GOS-E 2,3 and 5 at the time of translation from ICU compared to the control group treated with mannitol. A significant difference was found for patients with neurological outcome GOSE 4 in favor of the mannitol group.

Keywords: hyperosmolar therapy, hypertonic saline, mannitol, traumatic brain injury, intracranial hypertension, brain edema treatment