Individualizing hyperosmolar therapy for management of intracranial hypertension
Intracranial hypertension is a major cause of morbidity and mortality in patients with brain injury. If not appropriately treated, it can precipitate brain ischemia, brain herniation and death. Hyperosmolar therapy remains the main armamentarium for management of raised intracranial pressure, especially in patients with diffuse lesions and where surgical options are not applicable. Substantial amount of studies have tried to explore the superiority of hypertonic saline or mannitol over the other. Due to significant heterogeneity in the pathophysiology of patients, variation in treatment threshold, method of drug administration and drug concentration, substantial evidence is lacking to support one agent over other. Hypertonic saline may be more effective than mannitol for lowering raised intracranial pressure. Well designed novel trials need to try to find the answer. Clinical, pathophysiological and biochemical data should be incorporated at bedside while individualizing selection of hyperosmolar therapy, with the aim to improve outcome and minimize harm.
1. Ropper AH. Management of raised intracranial
pressure and hyperosmolar therapy. Pract Neurol
2. Cadena R, Shoykhet M, Ratcliff JJ. Emergency
neurological life support: Intracranial
hypertension and herniation. Neurocrit Care 2017
Sep 14. doi: 10.1007/s12028-017-0454-z. [Epub
ahead of print]
3. Stocchetti N, Maas AI. Traumatic intracranial
hypertension. N Engl J Med 2014;370:2121-30.
4. Brophy GM, Human T. Pharmacotherapy pearls
for emergency neurological life support. Neurocrit
Care 2017 Sep 14. doi: 10.1007/s12028-017-0456-
x. [Epub ahead of print]
5. Carney N, Totten AM, O'Reilly C, Ullman JS,
Hawryluk GW, Bell MJ, et al. Guidelines for the
management of severe traumatic brain injury,
fourth edition. Neurosurgery 2017;80:6-15.
6. Rickard AC, Smith JE, Newell P, Bailey A, Kehoe
A, Mann C. Salt or sugar for your injured brain? A
meta-analysis of randomised controlled trials of
mannitol versus hypertonic sodium solutions to
manage raised intracranial pressure in traumatic
brain injury. Emerg Med J 2014;31:679-83.
7. Li M, Chen T, Chen SD, Cai J, Hu YH. Comparison
of equimolar doses of mannitol and hypertonic
saline for the treatment of elevated intracranial
pressure after traumatic brain injury: a systematic
review and meta-analysis. Medicine (Baltimore)
8. Menon DK, Ercole A. Critical care management
of traumatic brain injury. Handb Clin Neurol
9. Hutchinson PJ, Kolias AG, Czosnyka M,
Kirkpatrick PJ, Pickard JD, Menon DK. Intracranial
pressure monitoring for severe traumatic brain
injury. BMJ 2013;346:f1000.
10. Maslove DM, Lamontagne F, Marshall JC,
Heyland DK. A path to precision in ICU. Crit Care
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