Abstract
BackgroundIntracranial hypertension (ICH) is a major cause of death after traumatic brain injury (TBI). Continuous hyperosmolar therapy (CHT) has been proposed for the treatment of ICH, but its effectiveness is controversial. We compared the mortality and outcomes in patients with TBI with ICH treated or not with CHT.MethodsWe included patients with TBI (Glasgow Coma Scale ≤ 12 and trauma-associated lesion on brain computed tomography (CT) scan) from the databases of the prospective multicentre trials Corti-TC, BI-VILI and ATLANREA. CHT consisted of an intravenous infusion of NaCl 20% for 24 hours or more. The primary outcome was the risk of survival at day 90, adjusted for predefined covariates and baseline differences, allowing us to reduce the bias resulting from confounding factors in observational studies. A systematic review was conducted including studies published from 1966 to December 2016.ResultsAmong the 1086 included patients, 545 (51.7%) developed ICH (143 treated and 402 not treated with CHT). In patients with ICH, the relative risk of survival at day 90 with CHT was 1.43 (95% CI, 0.99–2.06, p = 0.05). The adjusted hazard ratio for survival was 1.74 (95% CI, 1.36–2.23, p < 0.001) in propensity-score-adjusted analysis. At day 90, favourable outcomes (Glasgow Outcome Scale 4–5) occurred in 45.2% of treated patients with ICH and in 35.8% of patients with ICH not treated with CHT (p = 0.06). A review of the literature including 1304 patients from eight studies suggests that CHT is associated with a reduction of in-ICU mortality (intervention, 112/474 deaths (23.6%) vs. control, 244/781 deaths (31.2%); OR 1.42 (95% CI, 1.04–1.95), p = 0.03, I2 = 15%).ConclusionsCHT for the treatment of posttraumatic ICH was associated with improved adjusted 90-day survival. This result was strengthened by a review of the literature.
Highlights
Intracranial hypertension (ICH) is a major cause of death after traumatic brain injury (TBI)
Effects of continuous hyperosmolar therapy in patients with traumatic brain injury with intracranial hypertension Blood levels of sodium were higher in patients with TBI with ICH than in patients without ICH (p < 0.001, Fig. 2a)
Blood levels of sodium were higher in patients with TBI with ICH treated with Continuous hyperosmolar therapy (CHT) than in those not treated with CHT (p < 0.001, Fig. 2a)
Summary
Intracranial hypertension (ICH) is a major cause of death after traumatic brain injury (TBI). Continuous hyperosmolar therapy (CHT) has been proposed for the treatment of ICH, but its effectiveness is controversial. We compared the mortality and outcomes in patients with TBI with ICH treated or not with CHT. Traumatic brain injury (TBI) is the most severe condition observed in trauma patients, given that nearly 33% of patients with TBI die in hospital and another 33% have poor neurological recovery [2]. Continuous infusion of hyperosmolar therapy has been proposed for the treatment of patients with severe brain injury, but its effects on survival and outcomes have been disappointing [9]
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