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Updated: May 29, 2026
Systems Analysis of the Neuroinflammatory and Hemodynamic Response to Traumatic Brain Injury
Published on: May 27, 2022
Osmolar therapy in pediatric traumatic brain injury
Tellen D Bennett1, Kimberly D Statler, E Kent Korgenski
1University of Utah School of Medicine, Salt Lake City, UT, USA. tell.bennett@hsc.utah.edu
Insights
Pediatric traumatic brain injury (TBI) care can be improved, as osmolar therapy use varies significantly. Guidelines influenced osmolar therapy trends, with hypertonic saline use increasing and mannitol use decreasing post-2003.
Area of Science:
- Pediatric critical care medicine
- Neurotrauma research
- Pharmacological interventions
Background:
- Mannitol and hypertonic saline are used to manage intracranial pressure in pediatric traumatic brain injury (TBI).
- Clinical practice patterns for osmolar therapy in pediatric TBI are not well-defined.
- The impact of expert guidelines on osmolar therapy use in pediatric TBI requires investigation.
Purpose of the Study:
- To describe the utilization patterns of mannitol and hypertonic saline in children with TBI.
- To assess associations between osmolar therapy use and patient/hospital characteristics.
- To evaluate the influence of 2003 pediatric TBI guidelines on osmolar therapy practices.
Main Methods:
- Retrospective cohort study utilizing the Pediatric Health Information System database (2001-2008).
- Inclusion criteria: children (<18 years) with TBI, head/neck Abbreviated Injury Scale score ≥ 3, mechanical ventilation, and intensive care.
- Primary outcome: hospital billing for parenteral hypertonic saline and mannitol use.
Main Results:
- Overall, 33% received hypertonic saline and 40% received mannitol.
- Nearly 30% of patients receiving osmolar therapy for ≥ 2 days lacked intracranial pressure monitoring.
- Use of both agents was associated with older age, intracranial hemorrhage, skull fracture, and higher injury severity. Hypertonic saline use increased, while mannitol use decreased after 2003 guidelines.
Conclusions:
- Significant patient and hospital-level variation exists in osmolar therapy for pediatric TBI.
- Opportunities for improving care include optimizing osmolar therapy use, particularly in relation to intracranial pressure monitoring.
- Published guidelines appear to significantly influence clinical practice in osmolar therapy for pediatric TBI.
Objectives:
To describe patterns of use for mannitol and hypertonic saline in children with traumatic brain injury, to evaluate any potential associations between hypertonic saline and mannitol use and patient demographic, injury, and treatment hospital characteristics, and to determine whether the 2003 guidelines for severe pediatric traumatic brain injury impacted clinical practice regarding osmolar therapy.
Design:
Retrospective cohort study.
Setting:
Pediatric Health Information System database, January, 2001 to December, 2008.
Patients:
Children (age <18 yrs) with traumatic brain injury and head/neck Abbreviated Injury Scale score ≥ 3 who received mechanical ventilation and intensive care.
Interventions:
: None.
Measurements And Main Results:
The primary outcome was hospital billing for parenteral hypertonic saline and mannitol use, by day of service. Overall, 33% (2,069 of 6,238) of the patients received hypertonic saline, and 40% (2,500 of 6,238) received mannitol. Of the 1,854 patients who received hypertonic saline or mannitol for ≥ 2 days in the first week of therapy, 29% did not have intracranial pressure monitoring. After adjustment for hospital-level variation, primary insurance payer, and overall injury severity, use of both drugs was independently associated with older patient age, intracranial hemorrhage (other than epidural), skull fracture, and higher head/neck injury severity. Hypertonic saline use increased and mannitol use decreased with publication of the 2003 guidelines, and these trends continued through 2008.
Conclusions:
Hypertonic saline and mannitol are used less in infants than in older children. The patient-level and hospital-level variation in osmolar therapy use and the substantial amount of sustained osmolar therapy without intracranial pressure monitoring suggest opportunities to improve the quality of pediatric traumatic brain injury care. With limited high-quality evidence available, published expert guidelines appear to significantly impact clinical practice in this area.
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