Abstract
Background: We performed a meta-analysis to evaluate the effect of hypertonic saline compared to mannitol for the management of elevated intracranial pressure in traumatic brain injury.Methods: A systematic literature search up to July 2021 was performed and 17 studies included 1,392 subjects with traumatic brain injury at the start of the study; 708 of them were administered hypertonic saline and 684 were given mannitol. They were reporting relationships between the effects of hypertonic saline compared to mannitol for the management of elevated intracranial pressure in traumatic brain injury. We calculated the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) to assess the effect of hypertonic saline compared to mannitol for the management of elevated intracranial pressure in traumatic brain injury using the dichotomous or continuous method with a random or fixed-effect model.Results: Hypertonic saline had significantly lower treatment failure (OR, 0.38; 95% CI, 0.15–0.98, p = 0.04), lower intracranial pressure 30–60 mins after infusion termination (MD, −1.12; 95% CI, −2.11 to −0.12, p = 0.03), and higher cerebral perfusion pressure 30–60 mins after infusion termination (MD, 5.25; 95% CI, 3.59–6.91, p < 0.001) compared to mannitol in subjects with traumatic brain injury.However, hypertonic saline had no significant effect on favorable outcome (OR, 1.61; 95% CI, 1.01–2.58, p = 0.05), mortality (OR, 0.59; 95% CI, 0.34–1.02, p = 0.06), intracranial pressure 90–120 mins after infusion termination (MD, −0.90; 95% CI, −3.21–1.41, p = 0.45), cerebral perfusion pressure 90–120 mins after infusion termination (MD, 4.28; 95% CI, −0.16–8.72, p = 0.06), and duration of elevated intracranial pressure per day (MD, 2.20; 95% CI, −5.44–1.05, p = 0.18) compared to mannitol in subjects with traumatic brain injury.Conclusions: Hypertonic saline had significantly lower treatment failure, lower intracranial pressure 30–60 mins after infusion termination, and higher cerebral perfusion pressure 30–60 mins after infusion termination compared to mannitol in subjects with traumatic brain injury. However, hypertonic saline had no significant effect on the favorable outcome, mortality, intracranial pressure 90–120 mins after infusion termination, cerebral perfusion pressure 90–120 mins after infusion termination, and duration of elevated intracranial pressure per day compared to mannitol in subjects with traumatic brain injury. Further studies are required to validate these findings.
Highlights
MATERIALS AND METHODSTraumatic brain injury is one of the main reasons for death and disability in the world
Hypertonic saline had no significant effect on the favorable outcome, mortality, intracranial pressure 90–120 mins after infusion termination, cerebral perfusion pressure 90–120 mins after infusion termination, and duration of elevated intracranial pressure per day compared to mannitol in subjects with traumatic brain injury [23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39]
The analysis of results should be done with carefulness due to the low number of studies for some parameters studied e.g., for a favorable outcome, mortality, and cerebral perfusion pressure 90–120 mins after infusion termination and the low sample size in most of the included studies (14 studies ≤100 subjects) in the meta-analysis; recommending the requirement for more studies to confirm these findings or probably to significantly affect the confidence in the effect assessment especially for the favorable outcome, mortality, and cerebral perfusion pressure with their very low p-value (p = 0.05, 0.06, and 0.06)
Summary
MATERIALS AND METHODSTraumatic brain injury is one of the main reasons for death and disability in the world. Present metaanalyses are limited to surrogate endpoints e.g., intracranial pressure or have not noticed significant differences in death or functional result between hypertonic saline and mannitol [12,13,14], guidelines highlight that existing data are inadequate to suggest one solution over the other, and suggest that additional studies are needed in this field [4,5,6]. It is still uncertain whether hypertonic saline is better than mannitol in the controlling of subjects with traumatic brain injury or not. We performed a meta-analysis to evaluate the effect of hypertonic saline compared to mannitol for the management of elevated intracranial pressure in traumatic brain injury
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