Department of Neurology, University of California, San Francisco, CA, USA.
Crit Care Med. 2011 Mar;39(3):554-9. doi: 10.1097/CCM.0b013e318206b9be.
Randomized trials have suggested that hypertonic saline solutions may be superior to mannitol for the treatment of elevated intracranial pressure, but their impact on clinical practice has been limited, partly by their small size. We therefore combined their findings in a meta-analysis.
We searched for relevant studies in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and ISI Web of Knowledge.
Randomized trials were included if they directly compared equiosmolar doses of hypertonic sodium solutions to mannitol for the treatment of elevated intracranial pressure in human subjects undergoing quantitative intracranial pressure measurement.
Two investigators independently reviewed potentially eligible trials and extracted data using a preformed data collection sheet. Disagreements were resolved by consensus or by a third investigator if needed. We collected data on patient demographics, type of intracranial pathology, baseline intracranial pressure, osms per treatment dose, quantitative change in intracranial pressure, and prespecified adverse events. Our primary outcome was the proportion of successfully treated episodes of elevated intracranial pressure.
Five trials comprising 112 patients with 184 episodes of elevated intracranial pressure met our inclusion criteria. In random-effects models, the relative risk of intracranial pressure control was 1.16 (95% confidence interval, 1.00-1.33), and the difference in mean intracranial pressure reduction was 2.0 mm Hg (95% confidence interval, -1.6 to 5.7), with both favoring hypertonic saline over mannitol. A mild degree of heterogeneity was present among the included trials. There were no significant adverse events reported.
We found that hypertonic saline is more effective than mannitol for the treatment of elevated intracranial pressure. Our meta-analysis is limited by the small number and size of eligible trials, but our findings suggest that hypertonic saline may be superior to the current standard of care and argue for a large, multicenter, randomized trial to definitively establish the first-line medical therapy for intracranial hypertension.
随机试验表明，高渗盐水溶液在治疗颅内压升高方面可能优于甘露醇，但由于其规模较小，其对临床实践的影响有限。因此，我们将它们的发现进行了荟萃分析。
我们在 MEDLINE、EMBASE、Cochrane 对照试验中心注册库（CENTRAL）、Scopus 和 ISI Web of Knowledge 中搜索了相关研究。
如果直接比较等渗剂量的高渗钠溶液与甘露醇治疗接受定量颅内压测量的人类受试者的颅内压升高的随机试验，则纳入随机试验。
两名研究人员独立审查了潜在的合格试验，并使用预先制定的数据收集表提取数据。如有分歧，通过协商或必要时由第三名研究人员解决。我们收集了患者人口统计学、颅内病理类型、基线颅内压、每剂量渗透压、颅内压定量变化以及预先指定的不良事件的数据。我们的主要结局是成功治疗颅内压升高发作的比例。
五项试验共纳入 112 名患者 184 例颅内压升高，符合我们的纳入标准。在随机效应模型中，颅内压控制的相对风险为 1.16（95%置信区间，1.00-1.33），平均颅内压降低差异为 2.0mmHg（95%置信区间，-1.6 至 5.7），均有利于高渗盐水优于甘露醇。纳入试验存在轻度异质性。没有报告严重不良事件。
我们发现高渗盐水在治疗颅内压升高方面比甘露醇更有效。我们的荟萃分析受到合格试验数量和规模较小的限制，但我们的发现表明，高渗盐水可能优于当前的标准治疗方法，并呼吁进行一项大型、多中心、随机试验，以明确确定颅内高血压的一线治疗方法。
