Department of Intensive Care Adults, Erasmus MC-University Medical Center, Rotterdam, The Netherlands.
Department of Public Health, Erasmus MC-University Medical Center, Rotterdam, The Netherlands.
J Neurotrauma. 2023 Jul;40(13-14):1352-1365. doi: 10.1089/neu.2022.0465. Epub 2023 May 11.
Increased intracranial pressure (ICP) is one of the most important modifiable and immediate threats to critically ill patients suffering from traumatic brain injury (TBI). Two hyperosmolar agents (HOAs), mannitol and hypertonic saline (HTS), are routinely used in clinical practice to treat increased ICP. We aimed to assess whether a preference for mannitol, HTS, or their combined use translated into differences in outcome. The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study is a prospective multi-center cohort study. For this study, patients with TBI, admitted to the intensive care unit (ICU), treated with mannitol and/or HTS, and aged ≥16 years were included. Patients and centers were differentiated based on treatment preference with mannitol and/or HTS based on structured, data-driven criteria such as first administered HOA in the ICU. We assessed influence of center and patient characteristics in the choice of agent using adjusted multi-variate models. Further, we assessed the influence of HOA preference on outcome using adjusted ordinal and logistic regression models, and instrumental variable analyses. In total, 2056 patients were assessed. Of these, 502 (24%) patients received mannitol and/or HTS in the ICU. The first received HOA was HTS for 287 (57%) patients, mannitol for 149 (30%) patients, or both mannitol and HTS on the same day for 66 (13%) patients. Two unreactive pupils were more common in patients receiving both (13, 21%), compared with patients receiving HTS (40, 14%) or mannitol (22, 16%). Center, rather than patient characteristics, was independently associated with the preferred choice of HOA (-value <0.05). ICU mortality and 6-month outcome were similar between patients preferably treated with mannitol compared with HTS (odds ratio [OR] = 1.0, confidence interval [CI] = 0.4-2.2; OR = 0.9, CI = 0.5-1.6, respectively). Patients who received both also had a similar ICU mortality and 6-month outcome compared with patients receiving HTS (OR = 1.8, CI = 0.7-5.0; OR = 0.6, CI = 0.3-1.7, respectively). We found between-center variability regarding HOA preference. Moreover, we found that center is a more important driver of the choice of HOA than patient characteristics. However, our study indicates that this variability is an acceptable practice given absence of differences in outcomes associated with a specific HOA.
颅内压升高（ICP）是创伤性脑损伤（TBI）重症患者最重要的可调节和即刻威胁之一。两种高渗剂（HOA），甘露醇和高渗盐水（HTS），通常在临床实践中用于治疗 ICP 升高。我们旨在评估对甘露醇、HTS 或联合使用的偏好是否转化为结果的差异。欧洲神经创伤有效性研究合作创伤性脑损伤（CENTER-TBI）研究是一项前瞻性多中心队列研究。在这项研究中，纳入了 ICU 中接受甘露醇和/或 HTS 治疗、年龄≥16 岁的 TBI 患者。根据基于结构化、数据驱动的标准（如 ICU 中首次使用的 HOA）区分患者和中心的治疗偏好。我们使用调整后的多变量模型评估了中心和患者特征对药物选择的影响。此外，我们使用调整后的有序和逻辑回归模型以及工具变量分析评估了 HOA 偏好对结果的影响。总共评估了 2056 名患者。其中，502 名（24%）患者在 ICU 中接受了甘露醇和/或 HTS。287 名（57%）患者首次接受的 HOA 是 HTS，149 名（30%）患者是甘露醇，66 名（13%）患者同一天接受了甘露醇和 HTS。接受两者治疗的患者中，有两个未反应的瞳孔更常见（13%，21%），而接受 HTS（40%，14%）或甘露醇（22%，16%）治疗的患者则较少见。与患者特征相比，中心是与首选 HOA 选择独立相关的因素（-值<0.05）。与接受 HTS 治疗的患者相比，首选甘露醇治疗的患者 ICU 死亡率和 6 个月预后相似（优势比[OR] = 1.0，置信区间[CI] = 0.4-2.2；OR = 0.9，CI = 0.5-1.6）。接受两者治疗的患者与接受 HTS 治疗的患者相比，ICU 死亡率和 6 个月预后相似（OR = 1.8，CI = 0.7-5.0；OR = 0.6，CI = 0.3-1.7）。我们发现 HOA 偏好存在中心间差异。此外，我们发现中心是 HOA 选择的一个更重要驱动因素，而不是患者特征。然而，我们的研究表明，鉴于与特定 HOA 相关的结果差异不存在，这种变异性是可以接受的做法。
