Abstract
Raised intracranial pressure (ICP) is a common complication in children with acute encephalopathies. It compromises cerebral perfusion leading to ischaemia and may cause death when the brainstem is compressed during trans-tentorial herniation. Osmotic agents are widely used to control raised ICP. Their use in children is mainly guided by studies in adults. We carried out this review to determine the best available evidence of the effectiveness of various osmotic agents and their effect on resolution of coma and outcome (neurological sequelae and mortality) in children with acute encephalopathies. We searched literature published between January 1966 and January 2008 on the use of osmotic agents in children aged between 0 and 16 years with acute encephalopathies. We searched Medline, Cochrane Library, EMBASE, Cumulative Index to Nursing and Allied Health Literature and other databases for both published and unpublished literature. We identified four randomized controlled trials (RCTs), three prospective observational studies, two retrospective studies and one case report. The use of hypertonic saline appeared to achieve greater reduction in ICP compared to mannitol, normal saline and ringer's lactate. This effect was sustained when it was given as a continuous infusion. Boluses of glycerol and mannitol achieved transient reduction in ICP. Use of repeated doses of oral glycerol was associated with lower mortality and neurological sequelae when compared to placebo in children with acute bacterial meningitis. Hypertonic saline was associated with lower mortality when compared to mannitol in children with non-traumatic encephalopathies. All agents resulted in reduction of ICP, albeit transient in a number of occasions. A sustained reduction in ICP is desirable and could be achieved by modifying the modes and rates of administration, factors that need further investigation. Hypertonic saline appears to boost cerebral perfusion pressure, an important determinant of outcome in acute encephalopathies. Hypertonic saline appears to achieve greater reduction in ICP than other osmotic agents. Oral glycerol seems to improve outcome among children with acute bacterial meningitis. However, the evidence is not sufficient to guide change of practice. More studies are needed to examine the safest and most efficacious concentrations of the various agents and the most effective routes and rates of administration of these agents.
Highlights
Raised intracranial pressure (ICP) is known to complicate both traumatic and non-traumatic encephalopathies
Raised ICP has consistently been shown to be an important determinant of outcome in children with central nervous system (CNS) infections and traumatic brain injuries (TBI) [1,4,5]
This review examines the effectiveness of osmotic agents in reducing ICP in children with acute encephalopathies and, the effect of osmotic agents on resolution of coma and clinical outcome in children with acute encephalopathies
Summary
Raised intracranial pressure (ICP) is known to complicate both traumatic and non-traumatic encephalopathies. It impairs cerebral perfusion and may cause death due to global ischaemia and intracranial herniation. Raised intracranial pressure (ICP) is a recognized feature of both traumatic and non-traumatic encephalopathies [1,2,3,4] It impairs cerebral perfusion pressure (CPP), leading to ischaemia, and may cause death by compressing the brainstem during intracranial herniation. Urea, sorbitol, glycerol and hypertonic saline (HS). These agents act mainly by reducing ICP via an osmotic gradient, they may have other beneficial effects. It has been shown to enhance cerebral microcirculation by reducing adhesions of polymorphonuclear cells and by stimulating local release of nitric oxide [14]
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