Francony Gilles, Fauvage Bertrand, Falcon Dominique, Canet Charles, Dilou Henri, Lavagne Pierre, Jacquot Claude, Payen Jean-Francois
Department of Anesthesiology and Critical Care, Albert Michallon Hospital, Grenoble, France.
Crit Care Med. 2008 Mar;36(3):795-800. doi: 10.1097/CCM.0B013E3181643B41.
To compare the effects of equimolar doses of 20% mannitol solution and of 7.45% hypertonic saline solution (HSS) in the treatment of patients with sustained elevated intracranial pressure (ICP).
Parallel, randomized, controlled trial.
Two intensive care units in a university hospital.
A total of 20 stable patients with a sustained ICP of >20 mm Hg secondary to traumatic brain injury (n = 17) or stroke (n = 3).
A single equimolar infusion (255 mOsm dose) of either 231 mL of 20% mannitol (mannitol group; n = 10 patients) or 100 mL of 7.45% hypertonic saline (HSS group; n = 10 patients) during 20 mins of administration.
ICP, arterial blood pressure, cerebral perfusion pressure, blood flow velocities of middle cerebral artery using continuous transcranial Doppler, brain tissue oxygen tension, serum sodium and osmolality, and urine output during a study period of 120 mins.
The two treatments equally and durably reduced ICP during the experiment. At 60 mins after the start of the infusion, ICP was reduced by 45% +/- 19% of baseline values (mean +/- sd) in the mannitol group vs. 35% +/- 14% of baseline values in the HSS group. Cerebral perfusion pressure and diastolic and mean blood flow velocities were durably increased in the mannitol group, resulting in lower values of pulsatility index at the different times of the experiment (p < .01 vs. HSS). No major changes in brain tissue oxygen tension were found after each treatment. Mannitol caused a significantly greater increase in urine output (p < .05) than HSS, although there was no difference in the vascular filling requirement between the two treatments. HSS caused a significant elevation of serum sodium and chloride at 120 mins after the start of the infusion (p < .01).
A single equimolar infusion of 20% mannitol is as effective as 7.45% HSS in decreasing ICP in patients with brain injury. Mannitol exerts additional effects on brain circulation through a possible improvement in blood rheology. Pretreatment factors, such as serum sodium, systemic hemodynamics, and brain hemodynamics, thus should be considered when choosing between mannitol and HSS for patients with increased ICP.
比较等摩尔剂量的20%甘露醇溶液和7.45%高渗盐水溶液（HSS）治疗颅内压（ICP）持续升高患者的效果。
平行、随机、对照试验。
一所大学医院的两个重症监护病房。
共有20例稳定患者，因创伤性脑损伤（n = 17）或中风（n = 3）导致ICP持续>20 mmHg。
在20分钟内单次输注等摩尔剂量（255 mOsm剂量）的231 mL 20%甘露醇（甘露醇组；n = 10例患者）或100 mL 7.45%高渗盐水（HSS组；n = 10例患者）。
在120分钟的研究期间，测量ICP、动脉血压、脑灌注压、使用连续经颅多普勒测量大脑中动脉血流速度、脑组织氧分压、血清钠和渗透压以及尿量。
在实验过程中，两种治疗方法均能同等程度且持久地降低ICP。输注开始后第60分钟，甘露醇组ICP降低至基线值的45%±19%（平均值±标准差），而HSS组为基线值的35%±14%。甘露醇组脑灌注压以及舒张期和平均血流速度持续增加，导致实验不同时间点的搏动指数值更低（与HSS组相比，p <.01）。每种治疗后未发现脑组织氧分压有重大变化。甘露醇导致的尿量增加显著大于HSS（p <.05），尽管两种治疗在血管充盈需求方面无差异。输注开始后120分钟，HSS导致血清钠和氯显著升高（p <.01）。
单次等摩尔输注20%甘露醇在降低脑损伤患者ICP方面与7.45% HSS效果相同。甘露醇可能通过改善血液流变学对脑循环产生额外影响。因此，在为ICP升高的患者选择甘露醇和HSS时，应考虑血清钠、全身血流动力学和脑血流动力学等预处理因素。
