Hypertonic saline for treating raised intracranial pressure: literature review with meta-analysis

A review

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Object

Currently, mannitol is the recommended first choice for a hyperosmolar agent for use in patients with elevated intracranial pressure (ICP). Some authors have argued that hypertonic saline (HTS) might be a more effective agent; however, there is no consensus as to appropriate indications for use, the best concentration, and the best method of delivery. To answer these questions better, the authors performed a review of the literature regarding the use of HTS for ICP reduction.

Methods

A PubMed search was performed to locate all papers pertaining to HTS use. This search was then narrowed to locate only those clinical studies relating to the use of HTS for ICP reduction.

Results

A total of 36 articles were selected for review. Ten were prospective randomized controlled trials (RCTs), 1 was prospective and nonrandomized, 15 were prospective observational trials, and 10 were retrospective trials. The authors did not distinguish between retrospective observational studies and retrospective comparison trials. Prospective studies were considered observational if the effects of a treatment were evaluated over time but not compared with another treatment.

Conclusions

The available data are limited by low patient numbers, limited RCTs, and inconsistent methods between studies. However, a greater part of the data suggest that HTS given as either a bolus or continuous infusion can be more effective than mannitol in reducing episodes of elevated ICP. A meta-analysis of 8 prospective RCTs showed a higher rate of treatment failure or insufficiency with mannitol or normal saline versus HTS.

Abbreviations used in this paper: BBB = blood-brain barrier; CBF = cerebral blood flow; CPP = cerebral perfusion pressure; EGOS = Extended Glasgow Outcome Scale; GCS = Glasgow Coma Scale; HES = hydroxyethyl starch; HTS = hypertonic saline; ICP = intracranial pressure; LR = Lactated Ringer; mRS = modified Rankin Scale; NS = normal saline; RCT = randomized controlled trial; SAH = subarachnoid hemorrhage; TBI = traumatic brain injury.

Article Information

Address correspondence to: R. Shane Tubbs, Ph.D., Pediatric Neurosurgery, Children's Hospital, 1600 7th Avenue South, ACC 400, Birmingham, Alabama 35233. email: shane.tubbs@chsys.org.

Please include this information when citing this paper: published online September 23, 2011; DOI: 10.3171/2011.7.JNS102142.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Forrest plot comparing the rates of treatment failure or insufficiency with HTS versus mannitol or NS for intracranial hypertension. M-H = Mantel-Haenszel.

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