Abstract
BackgroundCurrent guidelines identify the choice of fluid resuscitation as important in minimizing the incidence of secondary brain injury from cerebral edema. It is widely accepted that isotonic crystalloid resuscitation fluids, specifically normal saline (NS), are optimal for resuscitation and that other relatively hypotonic fluids, such as Ringer’s lactate (RL), should be avoided in this patient population. The aim of this review is to systematically compare the use of relatively hypotonic versus isotonic crystalloid resuscitation fluids in clinical and pre-clinical models of acute brain injury and their effect on outcomes. In recognition of the potential need for a network meta-analysis (NMA), we have also included all other relevant crystalloid resuscitation fluids as interventions of relevance to potentially inform indirect comparisons.MethodsSystematic searches of MEDLINE, Embase, and Web of Science BIOSIS Previews® will be used to identify eligible clinical and pre-clinical studies, which included studies examining acute brain injury (human and in vivo animal brain injury models) within the first 7 days of therapy. The intervention of interest is the intravenous use of relatively hypotonic crystalloid resuscitation fluids (e.g., Ringer’s lactate, Hartmann’s or Plasma Lyte® fluids). The main comparator of interest is an isotonic crystalloid resuscitation fluid, specifically normal saline (0.9%). Other crystalloid resuscitation fluids (e.g., hypertonic saline (3–23.4%)) will also be included as an additional intervention of interest. The primary outcome measures of interest are intracranial pressure (ICP) and cerebral perfusion pressure (CPP). Secondary outcomes include the effect of resuscitation on cerebral edema, brain and serum osmolarity, and electrolyte concentrations and clinical outcomes including modified Rankin Scale (mRS), (extended) Glasgow Outcome Scale (GOS/eGOS), and mortality. Separate meta-analyses will be conducted to quantify the effects of the different fluid resuscitation on acute brain injury outcomes in clinical and pre-clinical populations. Network meta-analyses to compare interventions will also be performed to compare the effects of different interventions.DiscussionThis systematic review will comprehensively summarize the difference in treatment efficacy of various crystalloid resuscitation fluids in acute brain injury. This review is essential to underscore the evidence, or lack thereof, present in the literature to date to support current preference-driven practice and to direct future study.Systematic review registrationPROSPERO #CRD42016042960
Highlights
Current guidelines identify the choice of fluid resuscitation as important in minimizing the incidence of secondary brain injury from cerebral edema
It is clinician preference that mainly dictates clinical practice, with considerable variation between institutions and specialties [5]. Efforts to resolve this discrepancy have been made in many areas of critical care research, including a systematic review comparing the use of crystalloid and colloid fluids for resuscitation in septic shock [6]
The primary objective of this review is to compare the effect of relatively hypotonic versus isotonic crystalloid resuscitation fluids (i.e., Ringer’s lactate, Hartmann’s, and Plasma Lyte® versus normal saline (0.9%)) for resuscitation in early acute brain injury on intracranial pressure (ICP) and cerebral perfusion pressure (CPP)
Summary
Current guidelines identify the choice of fluid resuscitation as important in minimizing the incidence of secondary brain injury from cerebral edema. Acute brain injury is a global health issue responsible for significant death and disability worldwide with rising incidence [1] It is associated with a complicated hospital course where the primary injury is commonly associated with further neurological damage, known as secondary brain injury, including ischemia, neuronal death cascades, cerebral edema, and inflammation [2,3,4]. It is clinician preference that mainly dictates clinical practice, with considerable variation between institutions and specialties [5] Efforts to resolve this discrepancy have been made in many areas of critical care research, including a systematic review comparing the use of crystalloid and colloid fluids for resuscitation in septic shock [6]. Existing work demonstrates that metabolic derangements are common and can further lead to secondary brain injury [7] Whether this is related to the consequence of fluid administration or the primary injury itself remains unclear. Management of such injuries presents a significant challenge to critical care medicine
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