Kerwin Andrew J, Schinco Miren A, Tepas Joseph J, Renfro William H, Vitarbo Elizabeth A, Muehlberger Michael
Department of Surgery, University of Florida Health Science Center, Jacksonville, Florida 32209, USA.
J Trauma. 2009 Aug;67(2):277-82. doi: 10.1097/TA.0b013e3181acc726.
Oncotic agents are a therapeutic mainstay for the management of intracranial hypertension. Both mannitol and varied concentrations of hypertonic saline (HTS) have been shown to be effective at reducing elevated intracranial pressure (ICP). We compared the safety and efficacy of 23.4% HTS to mannitol for acute management of elevated ICP after traumatic brain injury (TBI).
After approval from our institutional review board, the records of patients admitted with severe TBI who received mannitol or HTS were reviewed. Demographic and physiologic data were recorded. ICP, cerebral perfusion pressure, reduction of ICP after dose administration, serum sodium, osmolality, and magnitude of dose response during the subsequent 60 minutes were analyzed. Efficacy was determined by comparison of proportion of patients with any response and mean change in ICP after dosing with either agent. Safety was determined by recording any new postinfusion electrolyte or neurologic anomalies. Data were compared using chi2 test, accepting p < 0.05 as significant.
Twenty-two patients with severe TBI received 210 doses of either mannitol or HTS. All patients suffered severe blunt injury (mean Injury Severity Score 28 +/- 11). HTS patients had a significantly higher ICP at the initiation of therapy than that of mannitol group (30.7 +/- 7.94 mm Hg vs. 28.3 +/- 8.07 mm Hg, respectively). There was no difference in initial cerebral perfusion pressure. Mean ICP reduction in the hour after administration of 102 doses of mannitol and 108 doses of HTS was greater for patients receiving HTS (9.3 +/- 7.37 mm Hg vs. 6.4 +/- 6.57 mm Hg, respectively; p = 0.0028, chi2). More patients responded to HTS (92.6% HTS vs. 74% mannitol; p = 0.0002, chi2). There was no significant difference between groups in the duration of ICP reduction after dose administration (4.1 hours vs. 3.8 hours, respectively). No adverse events after administration of either agent were identified.
Based on this retrospective analysis, 23.4% HTS is more efficacious than mannitol in reducing ICP. If these results are confirmed in a prospective, randomized study, 23.4% HTS may become the agent of choice for the management of elevated ICP after TBI.
胶体渗透压调节剂是治疗颅内高压的主要手段。甘露醇和不同浓度的高渗盐水（HTS）均已被证明在降低升高的颅内压（ICP）方面有效。我们比较了23.4%高渗盐水与甘露醇在创伤性脑损伤（TBI）后急性处理升高的ICP的安全性和有效性。
经我们机构审查委员会批准后，对接受甘露醇或高渗盐水治疗的重度TBI患者的记录进行了回顾。记录人口统计学和生理学数据。分析ICP、脑灌注压、给药后ICP的降低情况、血清钠、渗透压以及随后60分钟内的剂量反应幅度。通过比较使用任一药物给药后有任何反应的患者比例和ICP的平均变化来确定疗效。通过记录任何新的输注后电解质或神经异常情况来确定安全性。使用卡方检验比较数据，以p<0.05为有统计学意义。
22例重度TBI患者接受了210剂甘露醇或高渗盐水治疗。所有患者均遭受严重钝性损伤（平均损伤严重度评分28±11）。高渗盐水组患者在治疗开始时的ICP显著高于甘露醇组（分别为30.7±7.94mmHg和28.3±8.07mmHg）。初始脑灌注压无差异。接受高渗盐水治疗的患者在输注102剂甘露醇和108剂高渗盐水后1小时内的平均ICP降低幅度更大（分别为9.3±7.37mmHg和6.4±6.57mmHg；p = 0.0028，卡方检验）。更多患者对高渗盐水有反应（高渗盐水组为92.6%，甘露醇组为74%；p = 0.0002，卡方检验）。给药后ICP降低的持续时间在两组之间无显著差异（分别为4.1小时和3.8小时）。未发现使用任一药物给药后的不良事件。
基于这项回顾性分析，23.4%高渗盐水在降低ICP方面比甘露醇更有效。如果这些结果在前瞻性随机研究中得到证实，23.4%高渗盐水可能成为TBI后处理升高的ICP的首选药物。
