Effects of two different doses of 3% hypertonic saline with mannitol during decompressive craniectomy following...

The current study was designed to compare the effects of two different doses of 3% hypertonic saline with mannitol on intraoperative events during decompressive craniectomy in traumatic brain injury (TBI). Primary outcome measures included assessment of intraoperative brain relaxation, hemodynamic variables, and serum electrolytes. Effect on the postoperative outcome, in terms of the Glasgow coma scale (GCS), length of stay in the ICU, and mortality were the secondary outcome measures.

Ninety patients with TBI undergoing craniotomy were enrolled. Patients were assigned to receive 300 mL (328 mOsm) of mannitol (n = 26, M) only or 300 mL of mannitol with 150 mL (482 mOsm) of 3% HS (n = 35, HS₁) or with 300 mL (636 mOsm) of 3% HS (n = 29, HS₂). Brain relaxation was assessed and if required, a rescue dose of mannitol (150 mL) was given. GCS was assessed preoperatively, 24 h postoperatively, and at the time of discharge from the ICU and total duration of stay was noted.

Acceptable brain relaxation was observed in 89.66% (n = 26, HS₂) and 80% (n = 28, HS₁) patients as compared to 46.1% (n = 12, M) patients (P < 0.001) with significantly less number of patients requiring rescue doses of mannitol in groups HS₁ and HS₂(n = 7 and 3, respectively) as compared to group M (n = 14) (P < 0.05). There was a significant improvement in GCS at 24 h and at the time of discharge from the ICU in patients with a severe head injury in group HS₂ (P = 0.029). In patients with moderate head injury there was a significant improvement in GCS at the time of discharge among all the three groups (P < 0.05).

Increasing osmotic load by addition of 3% HS to mannitol provides better intraoperative brain relaxation than mannitol alone during decompressive craniectomy. An addition of 300mL 3% HS was found to be more effective in improving GCS in patients with severe TBI.