Association of early hyperosmolar therapy and operative interventions in severe traumatic brain injury

Hyperosmolar therapy, hypertonic saline (HTS) or mannitol (MAN), is one of the standard management algorithms in Traumatic Brain Injury (TBI). There is a gap in information regarding the impact of the timing of starting the hyperosmolar therapy and outcomes. Our hypothesis was that early hyperosmolar therapy would reduce the operative interventions (craniotomy or craniectomy).

The Trauma Quality Improvement Program (TQIP) database of 2019-2023 was queried for the study. Patients aged 18 years and older who suffered severe TBI, defined on Glasgow Coma Scale (GCS) score 8 or less and Abbreviated (brain) Injury Scale (AIS) score 3-5, who received HTS or MAN were included in the study. The propensity score matching method was used to compare the patients' characteristics and outcomes between the early (hyperosmolar therapy time of start ≤3 h after admission) and late groups (the therapy was started >3 h after admission).

A total of 673 patients fulfilled the inclusion criteria. Propensity score matching resulted in 174 pairs of patients. There were no significant differences found between the early and late groups regarding the age in years (median [IQR]: 49.5 [ 30.5-70] vs 53.5 [ 35-66], P = 0.765), GCS (median [IQR]: 3 [3-6] vs. 3 [3-6], P = 0.718), Injury Severity Score (ISS) (median [IQR]: 25[17-26] vs. 25[17-26], P = 0.85), non-reactive pupils ( n (%): 28.7% vs. 28.7%) and significant midline shift ( 48.9% vs. 48.9%). The pair-matched analysis showed no significant difference between the early and late groups in operative interventions (13.8% vs. 20.1%, P = 0.161) and operative intervention within 24 h (10.3% vs. 17.8%, P = 0.67) or overall mortality (37.4% vs. 31.6%, P = 0.295). There was a significantly lower number of ICU days (median [IQR]: 6 [3-10] vs. 8 [3-14], P = 0.026), and ventilator days (median [IQR]: 4 [2-8] vs. 5 [2-12.8], P = 0.008) identified in the early group when compared to the late group, respectively.

Starting hyperosmolar therapy within 3 h of hospital admission in severe TBI patients was not associated with any differences in operative interventions, overall mortality, but was associated with shorter ventilator days and intensive care (ICU) days.