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Study supports use of hypertonic saline in pediatric TBI

JAMA Network Open
Reuters Health - 31/03/2022 - In children with severe traumatic brain injury (TBI), giving a bolus of hypertonic saline is associated with "a significant, albeit relatively modest, reduction" in intracranial pressure during the initial hour of treatment, while bolus mannitol is not, according a new study. 

"Hyperosmolar agents are cornerstone therapies for pediatric severe traumatic brain injury," researchers note in JAMA Network Open, but the evidence for using hypertonic saline (HTS), let alone mannitol, is weak. 

To investigate, Dr. Michael Bell of Children's National Hospital in Washington, D.C., and colleagues analyzed data from eight countries on 1,000 consecutive children (ages from birth to 18) with TBI. More than three-quarters of the patients received some form of hyperosmolar therapy during the intracranial pressure (ICP)-directed phase of care; 518 received separate bolus doses of both mannitol and 3% HTS. 

The researchers note that the cohort mimicked patients seen in randomized clinical trials, for age (mean, 7 years), Glasgow Coma Scale score (mean, 5.2), and gender (65% male). The most common causes of injury were motor vehicle accidents, followed by falls. Abuse was "probable" or "definite" in nearly 13% of cases. 

With HTS, mean ICP dropped by 1.03 mmHg (P<0.001), whereas the decrease with mannitol was only 0.20 mmHg (P=0.44). 

After adjustment for dosing, verbal score, sex, cause of injury, likelihood of injury from abuse, likelihood of intentional injury, lower extremity Abbreviated Injury Scale score and epidural hematoma, the difference between the two agents was no longer significant. 

However, at an ICP greater than 25 mmHg, the response with HTS was significantly greater than with mannitol after adjustment. No differences in CPP between HTS and mannitol were seen. 

Although the findings appear to favor HTS, "each clinical situation is quite different, and there are many factors that any clinician needs to consider when choosing how to stave off these crises for the best outcomes for their patients," Dr. Bell told Reuters Health by email. 

Progress in head injury research has been slow and challenging, he noted, in part because "patients who have a severe head injury often have other conditions that are life-threatening: injuries to other organs, shock and other conditions." 

In an accompanying editorial, Dr. Geoffrey T. Manley of the University of California, San Francisco, and colleagues note that treatments for abnormalities in brain water balance "have changed little since the introduction of intravenous injections of hypertonic solutions . . . more than 100 years ago." 

"This large, multicenter study provides real-world evidence, in conjunction with the current pediatric TBI guidelines, that supports the use of HTS as a first-line agent in the management of pediatric TBI." 

In an email to Reuters Health, Dr. Caroline M. Sierra of the Loma Linda University School of Pharmacy, in California, agreed with Dr. Bell that "one of the major challenges with assessing hyperosmolar therapy is the many confounding factors: cause of injury, time to treatment, other medications administered, clinical presentation, resources available at the treating institution, medical interventions, etc." 

She added that despite the authors' having assembled a large patient population, thus being able to account for some confounders, "the difference in outcomes between the therapies was minimal." 

"Additionally, no clinical correlation is presented, so it is uncertain if there is a difference in morbidity or mortality with either therapy," continued Dr. Sierra, who was not involved in the study. "That said, this study with a large and varied patient population provides valuable data regarding outcomes of two commonly administered hyperosmolar therapies in pediatric TBI." 

SOURCE: https://bit.ly/3NiCVp3  JAMA Network Open, online March 10, 2022. 

By Scott Baltic 

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