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Hyperosmolar Therapy in Pediatric Severe Traumatic Brain Injury-A Systematic Review
Brittany M Stopa1, Rianne G F Dolmans1,2, Marike L D Broekman2,3
1Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Insights
Hyperosmolar therapy, including hypertonic saline and mannitol, may reduce intracranial pressure in children with severe traumatic brain injury. However, evidence is limited, making it difficult to determine the most effective agent or treatment protocol.
Area of Science:
- Pediatric critical care medicine
- Neuroscience
- Pharmacology
Background:
- Traumatic brain injury (TBI) is a significant cause of pediatric hospitalizations.
- Hyperosmolar therapy is a common treatment for severe TBI.
- The comparative efficacy of hypertonic saline versus mannitol remains debated.
Purpose of the Study:
- To systematically review the literature on hyperosmolar therapy for pediatric severe TBI.
- To compare the effectiveness of hypertonic saline and mannitol in managing intracranial pressure and clinical outcomes.
Main Methods:
- Systematic review of studies from PubMed, Cochrane, and Embase.
- Inclusion of retrospective and prospective studies on pediatric TBI patients.
- Quality assessment using Modified Newcastle-Ottawa Scale and Jadad score.
Main Results:
- Eleven studies involving 358 patients were analyzed.
- Both hypertonic saline and mannitol demonstrated a reduction in intracranial pressure.
- Data on clinical outcomes were heterogeneous, with varying treatment protocols and outcome measures.
Conclusions:
- Both agents appear to lower intracranial pressure and improve outcomes in pediatric severe TBI.
- Evidence is fragmented, hindering definitive conclusions on agent superiority or optimal protocols.
- Further high-quality comparative studies are needed to guide treatment decisions.
Objectives:
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.
Data Sources:
Literature search was conducted using Pubmed, Cochrane, and Embase. Systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
Study Selection:
Retrospective and prospective studies assessing use of hyperosmolar therapy in pediatric patients with severe traumatic brain injury were included.
Data Extraction:
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.
Data Synthesis:
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%.
Conclusions:
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.
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