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Open Access 01-10-2005 | Research

Efficiency of 7.2% hypertonic saline hydroxyethyl starch 200/0.5 versus mannitol 15% in the treatment of increased intracranial pressure in neurosurgical patients – a randomized clinical trial [ISRCTN62699180]

Authors: Lilit Harutjunyan, Carsten Holz, Andreas Rieger, Matthias Menzel, Stefan Grond, Jens Soukup

Published in: Critical Care | Issue 5/2005

Abstract

Introduction

This prospective randomized clinical study investigated the efficacy and safety of 7.2% hypertonic saline hydroxyethyl starch 200/0.5 (7.2% NaCl/HES 200/0.5) in comparison with 15% mannitol in the treatment of increased intracranial pressure (ICP).

Methods

Forty neurosurgical patients at risk of increased ICP were randomized to receive either 7.2% NaCl/HES 200/0.5 or 15% mannitol at a defined infusion rate, which was stopped when ICP was < 15 mmHg.

Results

Of the 40 patients, 17 patients received 7.2% NaCl/HES 200/0.5 and 15 received mannitol 15%. In eight patients, ICP did not exceed 20 mmHg so treatment was not necessary. Both drugs decreased ICP below 15 mmHg (p < 0.0001); 7.2% NaCl/HES 200/0.5 within 6.0 (1.2–15.0) min (all results are presented as median (minimum-maximum range)) and mannitol within 8.7 (4.2–19.9) min (p < 0.0002). 7.2% NaCl/HES 200/0.5 caused a greater decrease in ICP than mannitol (57% vs 48%; p < 0.01). The cerebral perfusion pressure was increased from 60 (39–78) mmHg to 72 (54–85) mmHg by infusion with 7.2% NaCl/HES 200/0.5 (p < 0.0001) and from 61 (47–71) mmHg to 70 (50–79) mmHg with mannitol (p < 0.0001). The mean arterial pressure was increased by 3.7% during the infusion of 7.2% NaCl/HES 200/0.5 but was not altered by mannitol. There were no clinically relevant effects on electrolyte concentrations and osmolarity in the blood. The mean effective dose to achieve an ICP below 15 mmHg was 1.4 (0.3–3.1) ml/kg for 7.2% NaCl/HES 200/0.5 and 1.8 (0.45–6.5) ml/kg for mannitol (p < 0.05).

Conclusion

7.2% NaCl/HES 200/0.5 is more effective than mannitol 15% in the treatment of increased ICP. A dose of 1.4 ml/kg of 7.2% NaCl/HES 200/0.5 can be recommended as effective and safe. The advantage of 7.2% NaCl/HES 200/0.5 might be explained by local osmotic effects, because there were no clinically relevant differences in hemodynamic clinical chemistry parameters.

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Lang EW, Chesnut RM: Intracranial pressure and cerebral perfusion pressure in severe head injury. New Horiz 1995, 3: 400-409.PubMed

Chesnut RM: Medical management of severe head injury: present and future. New Horiz 1995, 3: 581-593.PubMed

Caroli M, Locatelli M, Campanella R, Balbi S, Martinelli F, Arienta C: Multiple intracranial lesions in head injury: clinical considerations, prognostic factors, management, and results in 95 patients. Surg Neurol 2001, 56: 82-88. 10.1016/S0090-3019(01)00540-7CrossRefPubMed

Procaccio F, Stocchetti N, Citerio G, Berardino M, Beretta L, Della Corte F, D'Avella D, Brambilla GL, Delfini R, Servadei F, Tomei G: Guidelines for the treatment of adults with severe head trauma (part II). Criteria for medical treatment. J Neurosurg Sci 2000, 44: 11-18.PubMed

Vukic M, Negovetic L, Kovac D, Ghajar J, Glavic Z, Gopcevic A: The effect of implementation of guidelines for the management of severe head injury on patient treatment and outcome. Acta Neurochir (Wien) 1999, 141: 1203-1208. 10.1007/s007010050419CrossRef

Rosner MJ, Rosner SD, Johnson AH: Cerebral perfusion pressure: management protocol and clinical results. J Neurosurg 1995, 83: 949-962.CrossRefPubMed

Rosner MJ: Introduction to cerebral perfusion pressure management. Neurosurg Clin N Am 1995, 6: 761-773.PubMed

Rosner MJ, Daughton S: Cerebral perfusion pressure management in head injury. J Trauma 1990, 30: 933-940. discussion 940-931CrossRefPubMed

Weed LH, McKibben PS: Experimental alteration of brain bulk. Am J Physiol 1919, 48: 531-558.

10.

Bullock R, Chesnut RM, Clifton G, Ghajar J, Marion DW, Narayan RK, Newell DW, Pitts LH, Rosner MJ, Wilberger JW: Guidelines for the management of severe head injury. Brain Trauma Foundation. Eur J Emerg Med 1996, 3: 109-127.CrossRefPubMed

11.

McMullen JE, Aoki H, Brown EB Jr, Kittle CF: Hemodynamic effects of tris (hydroxymethyl) aminomethane. Surg Forum 1965, 16: 188-191.PubMed

12.

Traeger SM, Henning RJ, Dobkin W, Giannotta S, Weil MH, Weiss M: Hemodynamic effects of pentobarbital therapy for intracranial hypertension. Crit Care Med 1983, 11: 697-701.CrossRefPubMed

13.

The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Use of barbiturates in the control of intracranial hypertension J Neurotrauma 2000, 17: 527-530.

14.

Nakayama S, Sibley L, Gunther RA, Holcroft JW, Kramer GC: Small-volume resuscitation with hypertonic saline (2,400 mOsm/liter) during hemorrhagic shock. Circ Shock 1984, 13: 149-159.PubMed

15.

Rocha-e-Silva M, Negraes GA, Soares AM, Pontieri V, Loppnow L: Hypertonic resuscitation from severe hemorrhagic shock: patterns of regional circulation. Circ Shock 1986, 19: 165-175.PubMed

16.

Maningas PA: Resuscitation with 7.5% NaCl in 6% dextran-70 during hemorrhagic shock in swine: effects on organ blood flow. Crit Care Med 1987, 15: 1121-1126.CrossRefPubMed

17.

Kempski O, Obert C, Mainka T, Heimann A, Strecker U: "Small volume resuscitation" as treatment of cerebral blood flow disturbances and increased ICP in trauma and ischemia. Acta Neurochir Suppl 1996, 66: 114-117.PubMed

18.

Berger S, Schurer L, Hartl R, Deisbock T, Dautermann C, Murr R, Messmer K, Baethmann A: 7.2% NaCl/10% dextran 60 versus 20% mannitol for treatment of intracranial hypertension. Acta Neurochir Suppl (Wien) 1994, 60: 494-498.

19.

De Vivo P, Del Gaudio A, Ciritella P, Puopolo M, Chiarotti F, Mastronardi E: Hypertonic saline solution: a safe alternative to mannitol 18% in neurosurgery. Minerva Anestesiol 2001, 67: 603-611.PubMed

20.

Erard AC, Walder B, Ravussin P: [Effects of equiosmolar load of 20% mannitol, 7.5% saline and 0.9% saline on plasma osmolarity, haemodynamics and plasma concentrations of electrolytes]. Ann Fr Anesth Reanim 2003, 22: 18-24.CrossRefPubMed

21.

Vialet R, Albanese J, Thomachot L, Antonini F, Bourgouin A, Alliez B, Martin C: Isovolume hypertonic solutes (sodium chloride or mannitol) in the treatment of refractory posttraumatic intracranial hypertension: 2 mL/kg 7.5% saline is more effective than 2 mL/kg 20% mannitol. Crit Care Med 2003, 31: 1683-1687. 10.1097/01.CCM.0000063268.91710.DFCrossRefPubMed

22.

Qureshi AI, Wilson DA, Traystman RJ: Treatment of elevated intracranial pressure in experimental intracerebral hemorrhage: comparison between mannitol and hypertonic saline. Neurosurgery 1999, 44: 1055-1063. discussion 1063-1054 10.1097/00006123-199905000-00064CrossRefPubMed

23.

Procaccio F, Stocchetti N, Citerio G, Berardino M, Beretta L, Della Corte F, D'Avella D, Brambilla GL, Delfini R, Servadei F, Tomei G: Guidelines for the treatment of adults with severe head trauma (part I). Initial assessment; evaluation and pre-hospital treatment; current criteria for hospital admission; systemic and cerebral monitoring. J Neurosurg Sci 2000, 44: 1-10.PubMed

24.

Bulger EM, Nathens AB, Rivara FP, Moore M, MacKenzie EJ, Jurkovich GJ: Management of severe head injury: institutional variations in care and effect on outcome. Crit Care Med 2002, 30: 1870-1876. 10.1097/00003246-200208000-00033CrossRefPubMed

25.

Ghajar J, Hariri RJ, Narayan RK, Iacono LA, Firlik K, Patterson RH: Survey of critical care management of comatose, head-injured patients in the United States. Crit Care Med 1995, 23: 560-567. 10.1097/00003246-199503000-00023CrossRefPubMed

26.

Jeevaratnam DR, Menon DK: Survey of intensive care of severely head injured patients in the United Kingdom. BMJ 1996, 312: 944-947.PubMedCentralCrossRefPubMed

27.

Matta B, Menon D: Severe head injury in the United Kingdom and Ireland: a survey of practice and implications for management. Crit Care Med 1996, 24: 1743-1748. 10.1097/00003246-199610000-00023CrossRefPubMed

28.

Garcia-Sola R, Pulido P, Capilla P: The immediate and long-term effects of mannitol and glycerol. A comparative experimental study. Acta Neurochir (Wien) 1991, 109: 114-121. 10.1007/BF01403005CrossRef

29.

Kofke WA, Tempelhoff R: Increased intracranial pressure in head trauma patients given fentanyl or sufentanil. Anesthesiology 1993, 78: 620-621.CrossRefPubMed

30.

Node Y, Yajima K, Nakazawa S: [Rebound phenomenon of mannitol and glycerol: clinical studies]. No To Shinkei 1983, 35: 1241-1246.PubMed

31.

Oken DE: Renal and extrarenal considerations in high-dose mannitol therapy. Ren Fail 1994, 16: 147-159.CrossRefPubMed

32.

Famularo G: The puzzle of neuronal death and life: is mannitol the right drug for the treatment of brain oedema associated with ischaemic stroke? Eur J Emerg Med 1999, 6: 363-368.CrossRefPubMed

33.

Videen TO, Zazulia AR, Manno EM, Derdeyn CP, Adams RE, Diringer MN, Powers WJ: Mannitol bolus preferentially shrinks non-infarcted brain in patients with ischemic stroke. Neurology 2001, 57: 2120-2122.CrossRefPubMed

34.

Gunnar W, Jonasson O, Merlotti G, Stone J, Barrett J: Head injury and hemorrhagic shock: studies of the blood brain barrier and intracranial pressure after resuscitation with normal saline solution, 3% saline solution, and dextran-40. Surgery 1988, 103: 398-407.PubMed

35.

Gunnar W, Kane J, Barrett J: Cerebral blood flow following hypertonic saline resuscitation in an experimental model of hemorrhagic shock and head injury. Braz J Med Biol Res 1989, 22: 287-289.PubMed

36.

Gunnar WP, Merlotti GJ, Barrett J, Jonasson O: Resuscitation from hemorrhagic shock. Alterations of the intracranial pressure after normal saline, 3% saline and dextran-40. Ann Surg 1986, 204: 686-692.PubMedCentralCrossRefPubMed

37.

Walsh JC, Zhuang J, Shackford SR: A comparison of hypertonic to isotonic fluid in the resuscitation of brain injury and hemorrhagic shock. J Surg Res 1991, 50: 284-292. 10.1016/0022-4804(91)90192-OCrossRefPubMed

38.

Prough DS, Johnson JC, Poole GV Jr, Stullken EH, Johnston WE Jr, Royster R: Effects on intracranial pressure of resuscitation from hemorrhagic shock with hypertonic saline versus lactated Ringer's solution. Crit Care Med 1985, 13: 407-411.CrossRefPubMed

39.

Prough DS, Johnson JC, Stump DA, Stullken EH, Poole GV Jr, Howard G: Effects of hypertonic saline versus lactated Ringer's solution on cerebral oxygen transport during resuscitation from hemorrhagic shock. J Neurosurg 1986, 64: 627-632.CrossRefPubMed

40.

Sheikh AA, Matsuoka T, Wisner DH: Cerebral effects of resuscitation with hypertonic saline and a new low-sodium hypertonic fluid in hemorrhagic shock and head injury. Crit Care Med 1996, 24: 1226-1232. 10.1097/00003246-199607000-00027CrossRefPubMed

41.

Battistella FD, Wisner DH: Combined hemorrhagic shock and head injury: effects of hypertonic saline (7.5%) resuscitation. J Trauma 1991, 31: 182-188.CrossRefPubMed

42.

Berger S, Schurer L, Hartl R, Messmer K, Baethmann A: Reduction of post-traumatic intracranial hypertension by hypertonic/hyperoncotic saline/dextran and hypertonic mannitol. Neurosurgery 1995, 37: 98-107.CrossRefPubMed

43.

Prough DS, Whitley JM, Taylor CL, Deal DD, DeWitt DS: Rebound intracranial hypertension in dogs after resuscitation with hypertonic solutions from hemorrhagic shock accompanied by an intracranial mass lesion. J Neurosurg Anesthesiol 1999, 11: 102-111.CrossRefPubMed

44.

Horn P, Munch E, Vajkoczy P, Herrmann P, Quintel M, Schilling L, Schmiedek P, Schurer L: Hypertonic saline solution for control of elevated intracranial pressure in patients with exhausted response to mannitol and barbiturates. Neurol Res 1999, 21: 758-764.PubMed

45.

Hartl R, Ghajar J, Hochleuthner H, Mauritz W: Hypertonic/hyperoncotic saline reliably reduces ICP in severely head-injured patients with intracranial hypertension. Acta Neurochir Suppl 1997, 70: 126-129.PubMed

46.

Khanna S, Davis D, Peterson B, Fisher B, Tung H, O'Quigley J, Deutsch R: Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in pediatric traumatic brain injury. Crit Care Med 2000, 28: 1144-1151. 10.1097/00003246-200004000-00038CrossRefPubMed

47.

Schwarz S, Schwab S, Bertram M, Aschoff A, Hacke W: Effects of hypertonic saline hydroxyethyl starch solution and mannitol in patients with increased intracranial pressure after stroke. Stroke 1998, 29: 1550-1555.CrossRefPubMed

48.

Suarez JI, Qureshi AI, Bhardwaj A, Williams MA, Schnitzer MS, Mirski M, Hanley DF, Ulatowski JA: Treatment of refractory intracranial hypertension with 23.4% saline. Crit Care Med 1998, 26: 1118-1122. 10.1097/00003246-199806000-00038CrossRefPubMed

49.

Mayer SA, Sacco RL, Shi T, Mohr JP: Neurologic deterioration in noncomatose patients with supratentorial intracerebral hemorrhage. Neurology 1994, 44: 1379-1384.CrossRefPubMed

50.

Qureshi AI, Safdar K, Weil J, Barch C, Bliwise DL, Colohan AR, Mackay B, Frankel MR: Predictors of early deterioration and mortality in black Americans with spontaneous intracerebral hemorrhage. Stroke 1995, 26: 1764-1767.CrossRefPubMed

51.

Munar F, Ferrer AM, de Nadal M, Poca MA, Pedraza S, Sahuquillo J, Garnacho A: Cerebral hemodynamic effects of 7.2% hypertonic saline in patients with head injury and raised intracranial pressure. J Neurotrauma 2000, 17: 41-51.CrossRefPubMed

52.

Qureshi AI, Suarez JI, Castro A, Bhardwaj A: Use of hypertonic saline/acetate infusion in treatment of cerebral edema in patients with head trauma: experience at a single center. J Trauma 1999, 47: 659-665.CrossRefPubMed

53.

Hartl R, Schurer L, Goetz C, Berger S, Rohrich F, Baethmann A: The effect of hypertonic fluid resuscitation on brain edema in rabbits subjected to brain injury and hemorrhagic shock. Shock 1995, 3: 274-279.CrossRefPubMed

54.

Shackford SR, Bourguignon PR, Wald SL, Rogers FB, Osler TM, Clark DE: Hypertonic saline resuscitation of patients with head injury: a prospective, randomized clinical trial. J Trauma 1998, 44: 50-58.CrossRefPubMed

55.

Worthley LI, Cooper DJ, Jones N: Treatment of resistant intracranial hypertension with hypertonic saline. Report of two cases. J Neurosurg 1988, 68: 478-481.CrossRefPubMed

56.

Kaufmann AM, Cardoso ER: Aggravation of vasogenic cerebral edema by multiple-dose mannitol. J Neurosurg 1992, 77: 584-589.CrossRefPubMed

57.

Wahl M: [Resistance regulation of cerebral vessels]. Fortschr Med 1973, 91: 1279.PubMed

58.

Bosse O, Kuschinsky W, Wahl M: [Effects of osmolarity changes on the resistance regulation of the pia mater vessels in the cat]. Pflugers Arch 1972,332(Suppl 332):R59.PubMed

59.

Kuschinsky W, Wahl M, Bosse O, Thurau K: Perivascular potassium and pH as determinants of local pial arterial diameter in cats. A microapplication study. Circ Res 1972, 31: 240-247.CrossRefPubMed

60.

Muizelaar JP, Wei EP, Kontos HA, Becker DP: Cerebral blood flow is regulated by changes in blood pressure and in blood viscosity alike. Stroke 1986, 17: 44-48.CrossRefPubMed

61.

Qureshi AI, Suarez JI: Use of hypertonic saline solutions in treatment of cerebral edema and intracranial hypertension. Crit Care Med 2000, 28: 3301-3313. 10.1097/00003246-200009000-00032CrossRefPubMed

62.

Schwarz S, Georgiadis D, Aschoff A, Schwab S: Effects of hypertonic (10%) saline in patients with raised intracranial pressure after stroke. Stroke 2002, 33: 136-140. 10.1161/hs0102.100877CrossRefPubMed

63.

Tseng MY, Al-Rawi PG, Pickard JD, Rasulo FA, Kirkpatrick PJ: Effect of hypertonic saline on cerebral blood flow in poor-grade patients with subarachnoid hemorrhage. Stroke 2003, 34: 1389-1396. 10.1161/01.STR.0000071526.45277.44CrossRefPubMed

Title: Efficiency of 7.2% hypertonic saline hydroxyethyl starch 200/0.5 versus mannitol 15% in the treatment of increased intracranial pressure in neurosurgical patients – a randomized clinical trial [ISRCTN62699180]
Authors: Lilit Harutjunyan
Carsten Holz
Andreas Rieger
Matthias Menzel
Stefan Grond
Jens Soukup
Publication date: 01-10-2005
Publisher: BioMed Central
Published in: Critical Care / Issue 5/2005
Electronic ISSN: 1364-8535
DOI: https://doi.org/10.1186/cc3767

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Efficiency of 7.2% hypertonic saline hydroxyethyl starch 200/0.5 versus mannitol 15% in the treatment of increased intracranial pressure in neurosurgical patients – a randomized clinical trial [ISRCTN62699180]

Abstract

Introduction

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusion

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