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A prospective, randomized, and controlled study of fluid management in children with severe head injury: lactated
Insights
Hypertonic saline is more effective than lactated Ringer's solution for treating severe head injuries in children. It leads to lower intracranial pressure (ICP) and higher cerebral perfusion pressure (CPP), requiring fewer interventions and shorter ICU stays.
Area of Science:
- Pediatric critical care medicine
- Neurotrauma management
- Fluid resuscitation strategies
Background:
- Severe head injury in children poses significant management challenges.
- Hypotonic fluid resuscitation can be detrimental in pediatric severe head injury.
- The choice of fluid resuscitation impacts neurological outcomes.
Purpose of the Study:
- To compare the effects of lactated Ringer's solution versus hypertonic saline in severely head-injured children.
- To evaluate the impact of fluid choice on intracranial pressure (ICP) and cerebral perfusion pressure (CPP).
- To assess the need for interventions, complication rates, and length of stay.
Main Methods:
- An open, randomized, prospective study involving 32 children with severe head injury (Glasgow Coma Score <8).
- Children received either lactated Ringer's solution or hypertonic saline.
- Standardized intensive care protocols were followed, monitoring ICP, CPP, and serum sodium concentrations.
Main Results:
- Hypertonic saline (group 2) required fewer interventions to maintain ICP <15 mm Hg compared to lactated Ringer's (group 1).
- Group 2 patients had significantly shorter ICU stays and mechanical ventilation times.
- Increased serum sodium concentrations correlated with lower ICP and higher CPP, particularly in the hypertonic saline group.
Conclusions:
- Hypertonic saline is superior to lactated Ringer's solution for managing severe pediatric head injuries.
- Elevated serum sodium levels are associated with improved ICP and CPP.
- Hypertonic saline treatment resulted in fewer complications and shorter ICU stays.
Objectives:
Resuscitation in severe head injury may be detrimental when given with hypotonic fluids. We evaluated the effects of lactated Ringer's solution (sodium 131 mmol/L, 277 mOsm/L) compared with hypertonic saline (sodium 268 mmol/L, 598 mOsm/L) in severely head-injured children over the first 3 days after injury.
Design:
An open, randomized, and prospective study.
Setting:
A 16-bed pediatric intensive care unit (ICU) (level III) at a university children's hospital.
Patients:
A total of 35 consecutive children with head injury.
Interventions:
Thirty-two children with Glasgow Coma Scores of <8 were randomly assigned to receive either lactated Ringer's solution (group 1) or hypertonic saline (group 2). Routine care was standardized, and included the following: head positioning at 30 degrees; normothermia (96.8 degrees to 98.6 degrees F [36 degrees to 37 degrees C]); analgesia and sedation with morphine (10 to 30 microg/kg/hr), midazolam (0.2 to 0.3 mg/kg/hr), and phenobarbital; volume-controlled ventilation (PaCO2 of 26.3 to 30 torr [3.5 to 4 kPa]); and optimal oxygenation (PaO2 of 90 to 105 torr [12 to 14 kPa], oxygen saturation of >92%, and hematocrit of >0.30).
Measurements And Main Results:
Mean arterial pressure and intracranial pressure (ICP) were monitored continuously and documented hourly and at every intervention. The means of every 4-hr period were calculated and serum sodium concentrations were measured at the same time. An ICP of 15 mm Hg was treated with a predefined sequence of interventions, and complications were documented. There was no difference with respect to age, male/female ratio, or initial Glasgow Coma Score. In both groups, there was an inverse correlation between serum sodium concentration and ICP (group 1: r = -.13, r2 = .02, p < .03; group 2: r = -.29, r2 = .08, p < .001) that disappeared in group 1 and increased in group 2 (group 1: r = -.08, r2 = .01, NS; group 2: r = -.35, r2 =.12, p < .001). Correlation between serum sodium concentration and cerebral perfusion pressure (CPP) became significant in group 2 after 8 hrs of treatment (r = .2, r2 = .04, p = .002). Over time, ICP and CPP did not significantly differ between the groups. However, to keep ICP at <15 mm Hg, group 2 patients required significantly fewer interventions (p < .02). Group 1 patients received less sodium (8.0 +/- 4.5 vs. 11.5 +/- 5.0 mmol/kg/day, p = .05) and more fluid on day 1 (2850 +/- 1480 vs. 2180 +/- 770 mL/m2, p = .05). They also had a higher frequency of acute respiratory distress syndrome (four vs. 0 patients, p = .1) and more than two complications (six vs. 1 patient, p = .09). Group 2 patients had significantly shorter ICU stay times (11.6 +/- 6.1 vs. 8.0 +/- 2.4 days; p = .04) and shorter mechanical ventilation times (9.5 +/- 6.0 vs. 6.9 +/- 2.2 days; p = .1). The survival rate and duration of hospital stay were similar in both groups.
Conclusions:
Treatment of severe head injury with hypertonic saline is superior to that treatment with lactated Ringer's solution. An increase in serum sodium concentrations significantly correlates with lower ICP and higher CPP. Children treated with hypertonic saline require fewer interventions, have fewer complications, and stay a shorter time in the ICU.