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  • The Salt Versus Sugar Debate: Urinary Sodium Losses Following Hypertonic Saline Administration Curtails its Superior Osmolar Effect in Comparision to Mannitol in Severe Traumatic Brain Injury

    Final Number:

    Aniruddha Tekkatte Jagannatha MBBS, MCh; sriganesh kamath MD, DM; Indira Devi; umamaheswara g s rao md

    Study Design:
    Clinical Trial

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2016 Annual Meeting

    Introduction: Osmotherapy forms an integral part in the management of patients with severe traumatic brain injury (TBI). An ideal choice between mannitol and HTS remains to be conclusively proven. More importantly, attention has not been paid to the long term osmolarity changes during the therapy. The current prospective randomised study aims at evaluating the effect of serum and urine osmolarity and sodium achieved with mannitol and HTS on ICP and outcome.

    Methods: Thirty-eight patients of severe TBI, aged between 15 and 70 years and managed as per BTF guidelines were allocated to receive equiosmolar doses of either 20% mannitol or 3% HTS for refractory intracranial hypertension. Demographic data, physiological variables, ICP, serum and urine osmolarity/sodium were collected over five days. Data was analyzed for relationship between serum and urine sodium over five days in patients receiving mannitol and HTS for severe TBI.

    Results: A total of 301 and 186 boluses of mannitol and HTS respectively were administered over five days. There was no difference between mannitol and HTS with respect to demography,type of brain injury and GOS. Serum sodium and osmolarity changes were similar between the groups(p=0.16 and 0.35 respectively). Urinary sodium excretion was significantly higher with HTS(p=0.02).The mean fall in ICP following a dose of hyperosmolar agent was 8.9 ± 8.4 mm Hg in the mannitol group and 10.1 ± 8.7 mm Hg in the hypertonic saline group (p - 0.135).

    Conclusions: During long-term administration of hyperosmolar agents in TBI, HTS is no more effective than mannitol in controlling ICP. A major reason for this lack of benefit is an increased urinary loss of sodium with HTS and consequent inability to achieve higher serum sodium and osmolarity levels.Therapy aimed at retaining sodium holds the key for superior osmolar effect and good outcome.

    Patient Care: This study aims at finding a better osmolar agent in the managenment of severe TBI. The reasons for inefficiency of HTS was investigated. The results gives a plethora of oppurtunities in improving its osmolar effect and hence improving the outcomes

    Learning Objectives: By the conclusion of this session,participants should be able to 1) compare the effects of mannitol and hypertonic saline in severe TBI 2) should be able to discuss the reasons for the similarities between the two osmolar agent 3) participants should be able to discuss the methods to improve the osmolar effect of HTS by other means.

    References: 1. Fisher B, Thomas D, Peterson B. Hypertonic saline lowers raised intracranial pressure in children after head trauma. J Neurosurg Anesthesiol 1992; 4:4–10 2. Härtl R, Ghajar J, Hochleuthner H, Mauritz W: Hypertonic/hyperoncotic saline reliably reduces ICP in severely head injured patients with intracranial hypertension. Acta Neurochir Suppl (Wien) 1997; 70:126–129 3. Cottenceau V, Masson F, Mahamid E, Petit L, Shik V, Sztark F, Zaaroor M, Soustie JF. Comparison of effects of equiosmolar doses of mannitol and hypertonic saline on cerebral blood flow and metabolism in traumatic brain injury. J Neurotrauma 2011; 28: 2003-2012 4. Cooper DJ, Myles PS, McDermott FT, Murray LJ, Laidlaw J, Cooper G, Tremayne AB, Bernard SS, Ponsford J; HTS Study Investigators. Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial. JAMA 2004;291(11):1350-7 5. Bulger EM, May S, Brasel KJ, Schreiber M, Kerby JD, Tisherman SA, Newgard C, Slutsky A, Coimbra R, Emerson S, Minei JP, Bardarson B, Kudenchuk P, Baker A, Christenson J, Idris A, Davis D, Fabian TC, Aufderheide TP, Callaway C, Williams C, Banek J, Vaillancourt C, van Heest R, Sopko G, Hata JS, Hoyt DB; ROC Investigators. Out-of-hospital hypertonic resuscitation following severe traumatic brain injury: a randomized controlled trial. JAMA 2010; 304(13):1455-64. 6. Roquilly A, Mahe PJ, Latte DD, Loutrel O, Champin P, Di Falco C, Courbe A, Buffenoir K, Hamel O, Lejus C, Sebille V, Asehnoune K. Continuous controlled-infusion of hypertonic saline solution in traumatic brain-injured patients: a 9-year retrospective study. Crit Care. 2011; 15(5):R260. 7. Huang SJ, Chang L, Han YY, Lee YC, Tu YK. Efficacy and safety of hypertonic saline solutions in the treatment of severe head injury Surg Neurol. 2006; 65:539–46 8. Horn P, Munch E, Vajkoczy P, et al. Hypertonic saline solution for control of elevated intracranial pressure in patients with exhausted response to mannitol and barbiturates. Neurol Res. 1999; 21:758–64. 9. Farahvar A, Gerber LM, Chiu YL, Härtl R, Froelich M, Carney N, Ghajar J.. Response to intracranial hypertension treatment as a predictor of death in patients with severe traumatic brain injury. J Neurosurg. 2011; 114(5):1471-8 10. Cottier PT, Weller JM, Hoobler SW. Effect of an intravenous sodium chloride load on renal hemodynamics and electrolyte excretion in essential hypertension. Circulation 1958; 17(4, Part 2):750-60 11. Baldwin D, Kahana EM, Clarke RW. Renal excretion of sodium and potassium in the dog. Am J Physiol 1950; 162: 655 12. Selkurt EE, Post RS. Renal clearance of sodium in the dog: Effect of increasing sodium load on reabsorptive mechanism. Am J Physiol 1950; 162: 639 13. Goldsmith C, Rector FC, Seldin DW. Evidence for a direct effect of serum sodium concentration on sodium reabsorption. J Clin Invest 1962; 41: 850-859 14. Edelman IS, Leibman J, O'meara MP, Birkenfeld LW. Interrelations between serum sodium concentration, serum osmolarity and total exchangeable sodium, total exchangeable potassium and total body water. J Clin Invest1958; 37: 1236-56 15.An equiosmolar study on early intracranial physiology and long term outcome in severe traumatic brain injury comparing mannitol and hypertonic saline Aniruddha Tekkatte Jagannatha c, Kamath Sriganesh b, Bhagavatula Indira Devi a,Ganne Sesha Umamaheswara Rao b,(ahead of print)

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