Chong Shu-Ling, Zhu Yanan, Wang Quan, Caporal Paula, Roa Juan D, Chamorro Freddy Israel Pantoja, Teran Miranda Thelma Elvira, Dang Hongxing, Gan Chin Seng, Abbas Qalab, Ardila Ivan J, Antar Mohannad Ahmad, Domínguez-Rojas Jesús A, Rodríguez María Miñambres, Watzlawik Natalia Zita, Gómez Arriola Natalia Elizabeth, Yock-Corrales Adriana, Lasso-Palomino Rubén Eduardo, Xiu Ming Mei, Ong Jacqueline S M, Kurosawa Hiroshi, Aparicio Gabriela, Liu Chunfeng, Samransamruajkit Rujipat, Jaramillo-Bustamante Juan C, Anantasit Nattachai, Chor Yek Kee, Turina Deborah M, Lee Pei Chuen, Flores Marisol Fonseca, Pilar Orive Francisco Javier, Ng Pei Wen Jane, González-Dambrauskas Sebastián, Lee Jan Hau
SingHealth Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore.
Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore.
JAMA Netw Open. 2025 Mar 3;8(3):e250438. doi: 10.1001/jamanetworkopen.2025.0438.
The use of hypertonic saline (HTS) vs mannitol in the control of elevated intracranial pressure (ICP) secondary to neurotrauma is debated.
To compare mortality and functional outcomes of treatment with 3% HTS vs 20% mannitol among children with moderate to severe traumatic brain injury (TBI) at risk of elevated ICP.
DESIGN, SETTING, AND PARTICIPANTS: This prospective, multicenter cohort study was conducted between June 1, 2018, and December 31, 2022, at 28 participating pediatric intensive care units in the Pediatric Acute and Critical Care Medicine in Asia Network (PACCMAN) and the Red Colaborativa Pediátrica de Latinoamérica (LARed) in Asia, Latin America, and Europe. The study included children (aged <18 years) with moderate to severe TBI (Glasgow Coma Scale [GCS] score ≤13).
Treatment with 3% HTS compared with 20% mannitol.
Multiple log-binomial regression analysis was performed for mortality, and multiple linear regression analysis was performed for discharge Pediatric Cerebral Performance Category (PCPC) scores and 3-month Glasgow Outcome Scale-Extended Pediatric Version (GOS-E-Peds) scores. Inverse probability of treatment weighting was also performed using the propensity score method to control for baseline imbalance between groups.
This study included 445 children with a median age of 5.0 (IQR, 2.0-11.0) years. More than half of the patients (279 [62.7%]) were boys, and 344 (77.3%) had severe TBI. Overall, 184 children (41.3%) received 3% HTS, 82 (18.4%) received 20% mannitol, 69 (15.5%) received both agents, and 110 (24.7%) received neither agent. The mortality rate was 7.1% (13 of 184 patients) in the HTS group and 11.0% (9 of 82 patients) in the mannitol group (P = .34). After adjusting for age, sex, presence of child abuse, time between injury and hospital arrival, lowest GCS score in the first 24 hours, and presence of extradural hemorrhage, no between-group differences in mortality, hospital discharge PCPC scores, or 3-month GOS-E-Peds scores were observed.
In this cohort study of children with moderate to severe TBI, the use of HTS was not associated with increased survival or improved functional outcomes compared with mannitol. Future large multicenter randomized clinical trials are required to validate these findings.
在控制神经创伤继发的颅内压升高（ICP）方面，高渗盐水（HTS）与甘露醇的使用存在争议。
比较3%高渗盐水与20%甘露醇治疗对有ICP升高风险的中度至重度创伤性脑损伤（TBI）儿童的死亡率和功能结局。
设计、设置和参与者：这项前瞻性、多中心队列研究于2018年6月1日至2022年12月31日在亚洲、拉丁美洲和欧洲的亚洲儿科急性和危重症医学网络（PACCMAN）和拉丁美洲儿科协作网络（LARed）的28个参与研究的儿科重症监护病房进行。该研究纳入了年龄小于18岁、中度至重度TBI（格拉斯哥昏迷量表[GCS]评分≤13）的儿童。
3%高渗盐水与20%甘露醇治疗。
对死亡率进行多对数二项回归分析，对出院时的儿科脑功能分类（PCPC）评分和3个月时的格拉斯哥扩展预后量表儿童版（GOS-E-Peds）评分进行多线性回归分析。还使用倾向评分法进行治疗加权的逆概率分析，以控制组间的基线不平衡。
本研究纳入了445名儿童，中位年龄为5.0（四分位间距，2.0 - 11.0）岁。超过一半的患者（279名[62.7%]）为男孩，344名（77.3%）患有重度TBI。总体而言，184名儿童（41.3%）接受了3%高渗盐水治疗，82名（18.4%）接受了20%甘露醇治疗，69名（15.5%）接受了两种药物治疗，110名（24.7%）未接受任何一种药物治疗。高渗盐水组的死亡率为7.1%（184名患者中的13名），甘露醇组为11.0%（82名患者中的9名）（P = 0.34）。在调整年龄、性别、虐待儿童情况、受伤至入院时间、最初24小时内最低GCS评分以及硬膜外出血情况后，未观察到两组在死亡率、出院时PCPC评分或3个月时GOS-E-Peds评分方面的差异。
在这项针对中度至重度TBI儿童的队列研究中，与甘露醇相比，使用高渗盐水与生存率增加或功能结局改善无关。未来需要进行大型多中心随机临床试验来验证这些发现。
