Evaluation of Efficacy of Hypertonic Saline and Mannitol in Combination in Patients with a Traumatic Brain Injury

Abstract

Title: Evaluation of Efficacy of Hypertonic Saline and Mannitol in Combination in Patients with a Traumatic Brain Injury Background: Traumatic Brain Injury (TBI) is a major cause of disability and death. In 2013, an estimated 2.5 million emergency department visits were related to TBI. In current practice, hyperosmolar therapy such as bolus doses of intravenous mannitol 20% and sodium chloride 3% are commonly used as single agents for the treatment of Cerebral Edema And Intracranial Pressure (ICP) reduction. The Brain Trauma Foundation guidelines do not recommend a preferred agent, nor do they comment on the use of these agents in combination. Currently, there are no published studies evaluating combination hyperosmolar therapy for ICP reduction. The primary objective of this study is to evaluate the efficacy of bolus doses of intravenous mannitol 20% and sodium chloride 3% utilized as monotherapy or in combination in patients with TBI. Methods: This single-center retrospective study identified cases using a medication usage report generated through the electronic medical record at Advocate Christ Medical Center. Subjects 14 years and older admitted to the trauma service following a diagnosis of TBI who received an intravenous bolus of mannitol 20% and/or sodium chloride 3% from August 1, 2013 through August 1, 2018 were included. Subjects without known trauma confirmed by radiographic imaging, those who received a sodium chloride 3% continuous infusion, pregnant patients, and those who expired within twentyfour hours of admission were excluded. The following data points were collected: age, weight, gender, race, serum creatinine, serum sodium, serum osmolality, mean arterial pressure, initial Glasgow Coma Score (GCS), diagnostic imaging, presence of cerebral edema and size of midline shift on computed tomography, dose and frequency of hyperosmolar agents, neurosurgical intervention, vasopressor requirements, intravenous fluids, Hospital And Intensive Care Unit (ICU) Length Of Stay (LOS). All data was recorded without patient identifiers, maintained confidentially, and was analyzed using descriptive and inferential statistics. Results: A total of 1000 patients were screened of which 176 met the inclusion/exclusion criteria. In-hospital mortality was experienced by 6 of 24 patients in the combination group compared to 18 of 152 patients in the monotherapy group (p=0.08). Statically significant reductions were seen in need for neurosurgical intervention (p=0.04), vasopressor utilization (p=0.03), and ICU LOS (p=0.02) demonstrating a benefit of monotherapy over combination. No difference was seen in laboratory values or vitals measurements. Conclusion: Combination therapy was associated with a trend towards increase mortality compared to monotherapy use.