Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Department of Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands.
Crit Care Med. 2019 Dec;47(12):e1022-e1031. doi: 10.1097/CCM.0000000000004003.
Traumatic brain injury is a leading cause of hospital visits for children. Hyperosmolar therapy is often used to treat severe traumatic brain injury. Hypertonic saline is used predominantly, yet there remains disagreement about whether hypertonic saline or mannitol is more effective.
Literature search was conducted using Pubmed, Cochrane, and Embase. Systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
Retrospective and prospective studies assessing use of hyperosmolar therapy in pediatric patients with severe traumatic brain injury were included.
Two independent authors performed article review. Two-thousand two-hundred thirty unique articles were initially evaluated, 11 were included in the final analysis, with a total of 358 patients. Study quality was assessed using Modified Newcastle-Ottawa Scale and Jadad score.
Of the 11 studies, all evaluated hypertonic saline and four evaluated both hypertonic saline and mannitol. Nine reported that hypertonic saline lowered intracranial pressure and two reported that mannitol lowered intracranial pressure. The studies varied significantly in dose, concentration, and administrations schedule for both hypertonic saline and mannitol. Five studies were prospective, but only one directly compared mannitol to hypertonic saline. The prospective comparison study found no difference in physiologic outcomes. Clinical outcomes were reported using different measures across studies. For hypertonic saline-treated patients, mechanical ventilation was required for 6.9-9 days, decompressive craniectomy was required for 6.25-29.3% of patients, ICU length of stay was 8.0-10.6 days, in-hospital mortality was 10-48%, and 6-month mortality was 7-17%. In mannitol-treated patients, ICU length of stay was 9.5 days, in-hospital mortality was 56%, and 6-month mortality was 19%.
Both hypertonic saline and mannitol appear to lower intracranial pressure and improve clinical outcomes in pediatric severe traumatic brain injury, but the evidence is extremely fractured both in the method of treatment and in the evaluation of outcomes. Given the paucity of high-quality data, it is difficult to definitively conclude which agent is better or what treatment protocol to follow.
颅脑创伤是导致儿童住院的主要原因。高渗疗法常用于治疗严重颅脑创伤。高渗盐水是主要使用的药物，但关于高渗盐水和甘露醇哪种更有效仍存在争议。
使用 Pubmed、Cochrane 和 Embase 进行文献检索。系统评价遵循系统评价和荟萃分析的 Preferred Reporting Items 指南。
纳入评估高渗疗法在儿童严重颅脑创伤患者中的应用的回顾性和前瞻性研究。
两名独立作者进行文章评价。最初评估了 2230 篇独特的文章，最终分析纳入了 11 篇，共有 358 名患者。使用改良纽卡斯尔-渥太华量表和 Jadad 评分评估研究质量。
在 11 项研究中，均评估了高渗盐水，其中 4 项研究同时评估了高渗盐水和甘露醇。9 项研究报告高渗盐水降低颅内压，2 项研究报告甘露醇降低颅内压。这些研究在高渗盐水和甘露醇的剂量、浓度和给药方案上差异显著。5 项研究为前瞻性研究，但仅有 1 项直接比较了甘露醇和高渗盐水。前瞻性比较研究发现生理结果无差异。临床结果在研究中使用不同的指标进行报告。高渗盐水治疗组患者机械通气时间为 6.9-9 天，去骨瓣减压术患者比例为 6.25-29.3%，重症监护病房住院时间为 8.0-10.6 天，院内死亡率为 10-48%，6 个月死亡率为 7-17%。甘露醇治疗组患者重症监护病房住院时间为 9.5 天，院内死亡率为 56%，6 个月死亡率为 19%。
高渗盐水和甘露醇似乎都能降低儿童严重颅脑创伤患者的颅内压并改善临床结果，但在治疗方法和结局评估方面，证据都极为分散。鉴于高质量数据的缺乏，很难确定哪种药物更好或应遵循哪种治疗方案。
