| Asehnoune K, Lasocki S, Seguin P et al. Critical Care, 2017; 21: 320. DOI 10.1186/s13054-017-1918-4 |
| Background | Traumatic brain injury (TBI) in people is associated with a high in-hospital mortality (33%) and poor neurological recovery (33%). Hyperosmolar agents are used to treat increased intracranial hypertension (ICH); whilst boluses of hyperosmolar agents have a transient effect on decreasing the intracranial pressure, the effects of continuous hyperosmolar therapy (CHT) on outcomes and survival have not been fully elucidated. |
| Rational and Objective |
Given findings of previous prospective and retrospective studies have given contradicting results on association of CHT on outcomes in TBI, the authors investigated the effects of early CHT in patients with TBI on:
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| Trial Design | Prospective multicenter cohort study performed using pooled individual patient data included in three previous different prospective trials (CORTI-TC, BI-VILI and ATLAN-REA studies). The authors also performed a systematic review of the existing literature, including the result of this trial. |
| Patient population and location | A multicentre study of people aged between 15-75 years with a duration of mechanical ventilation >24 hours and moderate/severe TBI (defined as GCS £12). |
| Methods | Patients receiving early CHT were compared to patients receiving boluses of hyperosmolar agents. In the control group, a bolus of hyperosmolar therapy (mannitol 0.25-1 g/kg or hypertonic saline 250 mOsm dose) was used as first line treatment and repeated in case of recurrence of ICH as required. In the study group (at one single center), early continuous hypertonic saline therapy (1 hour bolus of 20% NaCl) was initiated as first line treatment followed by 24 hours or more infusion of hypertonic saline titrated to target natremia according to the evolution of ICP. Systematic review was performed following MOOSE guidelines. |
| Endpoints (if applicable) |
Primary endpoint: risk of survival at 90 days Secondary endpoint: dichotomized Glasgow Outcome Scale (GOS) at 90 days (GOS 1-3 vs 4-5) The outcomes selected for the systematic review were:
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| Results |
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| Limitations |
This study only assesses associations but not causality in relation to reduced mortality. Early CHT was employed in one single center compared to standard treatment performed in other centers, therefore center-effects on outcomes cannot be excluded. |
| Clinical Relevance Conclusions |
In this trial and following a systematic review, early use of CHT was associated with survival at 90 days and reduced mortality respectively, suggesting it could be used in people with TBI at high risk of or as a first line treatment of ICH. Risk of severe hypernatremia exists, and close monitoring should be performed to avoid adverse events. |