Effects of hypertonic saline on intracranial pressure and cerebral autoregulation in pediatric traumatic brain injury

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  • 1 Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Tuebingen, Tuebingen;
  • | 2 Pediatric Intensive Care Unit, University Children’s Hospital of Tuebingen, Tuebingen; and
  • | 3 Department of Spine Surgery, Isar Klinikum, Munich, Germany
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OBJECTIVE

Hypertonic saline (HTS) is commonly used in children to lower intracranial pressure (ICP) after severe traumatic brain injury (sTBI). While ICP and cerebral perfusion pressure (CPP) correlate moderately to TBI outcome, indices of cerebrovascular autoregulation enhance the correlation of neuromonitoring data to neurological outcome. In this study, the authors sought to investigate the effect of HTS administration on ICP, CPP, and autoregulation in pediatric patients with sTBI.

METHODS

Twenty-eight pediatric patients with sTBI who were intubated and sedated were included. Blood pressure and ICP were actively managed according to the autoregulation index PRx (pressure relativity index to determine and maintain an optimal CPP [CPPopt]). In cases in which ICP was continuously > 20 mm Hg despite all other measures to decrease it, an infusion of 3% HTS was administered. The monitoring data of the first 6 hours after HTS administration were analyzed. The Glasgow Outcome Scale (GOS) score at the 3-month follow-up was used as the primary outcome measure, and patients were dichotomized into favorable (GOS score 4 or 5) and unfavorable (GOS score 1–3) groups.

RESULTS

The mean dose of HTS was 40 ml 3% NaCl. No significant difference in ICP and PRx was seen between groups at the HTS administration. ICP was lowered significantly in all children, with the effect lasting as long as 6 hours. The lowering of ICP was significantly greater and longer in children with a favorable outcome (p < 0.001); only this group showed significant improvement of autoregulatory capacity (p = 0.048). A newly established HTS response index clearly separated the outcome groups.

CONCLUSIONS

HTS significantly lowered ICP in all children after sTBI. This effect was significantly greater and longer-lasting in children with a favorable outcome. Moreover, HTS administration restored disturbed autoregulation only in the favorable outcome group. This highlights the role of a “rescuable” autoregulation regarding outcome, which might be a possible indicator of injury severity. The effect of HTS on autoregulation and other possible mechanisms should be further investigated.

ABBREVIATIONS

CPP = cerebral perfusion pressure; CPPopt = optimal CPP; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; HRI = HTS response index; HTS = hypertonic saline; ICP = intracranial pressure; MAP = mean arterial pressure; PRx = pressure relativity index; ROC = receiver operating characteristic; sTBI = severe traumatic brain injury.

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