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Hypertonic Saline vs. Mannitol in Management of Elevated Intracranial Pressure in Children: A Meta-Analysis

Nihar Ranjan Mishra1, Amit Agrawal2, Rashmi Ranjan Das3

  • 1Department of Pediatrics, All India Institute of Medical Sciences, Kalyani, West Bengal, India.

Indian Journal of Pediatrics
|May 24, 2023
PubMed

Insights

Hypertonic saline and mannitol show no significant difference in reducing elevated intracranial pressure (ICP) in children. Evidence for mortality is low certainty, necessitating further high-quality trials.

Area of Science:

  • Pediatric Critical Care Medicine
  • Neuroscience
  • Pharmacology

Background:

  • Elevated intracranial pressure (ICP) is a critical condition in children, often managed with hyperosmolar agents.
  • Hypertonic saline and mannitol are commonly used, but their comparative efficacy and safety in pediatric populations require clear evidence.

Approach:

  • A meta-analysis of four randomized controlled trials (RCTs) involving 365 pediatric patients was conducted.
  • The GRADE system assessed the certainty of evidence for primary (mortality) and secondary outcomes.
  • Searches were performed across relevant databases up to May 31, 2022.

Key Points:

  • No significant difference in mortality rates was observed between hypertonic saline and mannitol groups (RR 1.09, 95% CI 0.74-1.6).
  • Serum osmolality was significantly higher with mannitol. Adverse events included higher rates of shock and dehydration with mannitol, and hypernatremia with hypertonic saline.
  • Certainty of evidence for mortality was low; for secondary outcomes, it ranged from very-low to moderate.

Conclusions:

  • Hypertonic saline and mannitol appear comparable for reducing elevated ICP in children, with no significant impact on mortality.
  • Current evidence is limited, highlighting the need for high-quality RCTs to guide clinical recommendations.
  • Further research is essential to definitively establish optimal treatment strategies and safety profiles.
Abstract

Keywords:
3% salineCPPCerebral edemaGCSICPOsmotic agentPediatric

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