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Title: Early osmotherapy in severe traumatic brain injury: an international multicentre study.
Austin Authors: Anstey, James;Taccone, Fabio;Udy, Andrew;Citerio, Giuseppe;Duranteau, Jacques;Ichai, Carole;Badenes, Rafael;Prowle, John;Ercole, Ari;Oddo, Mauro;Schneider, Antoine;van der Jagt, Mathieu;Wolf, Stefan;Helbok, Raimund;Nelson, David;Skrifvars, Markus Benedict;Harrois, Anatole;Presneill, Jeffrey;Cooper, D James;Bailey, Michael;Bellomo, Rinaldo 
Affiliation: Charite Universitatsmedizin Berlin, 14903, Department of Neurosurgery, Berlin, Berlin, Germany
Helsinki University Hospital and University of Helsinki, Department of Anesthesia, Intensive Care and Pain Medicine , PL 700 (Haartmaninkatu 8) , Helsinki, Finland , 00029
The Alfred, Intensive Care , Commercial Road , Melbourne, Victoria, Australia , 3004
Monash University, ANZIC-RC , Level 6 , The Alfred Centre , 99 Commercial Road , Melbourne, Victoria, Australia , 3004
Monash University School of Public Health and Preventive Medicine, 161667, ANZIC-RC , 55 Commercial Road , Melbourne, Australia , 3004
Medizinische Universitat Innsbruck, 27280, Neurological Intensive Care Unit, Innsbruck, Tirol, Austria
Karolinska Institutet Department of Physiology and Pharmacology, 111126, Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Stockholms, Sweden
University of Melbourne, 2281, Department of Medicine and Radiology, Melbourne, Victoria, Australia
Monash University, School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
Hopitaux Universitaires Paris-Sud, 378965, Department of Anesthesia and Intensive Care, Le Kremlin-Bicetre, Île-de-France, France
Royal Melbourne Hospital, 90134, Intensive Care Unit, Melbourne, Australia
The Alfred, Department of Intensive Care and Hyperbaric Medicine , Commercial Road , Prahran , Melbourne, Victoria, Australia , 3145
Azienda Ospedaliera San Gerardo, 9265, Perioperative Medicine and Intensive Care Medicine , Cadore , Monza, Lombardia, Italy , 20060
Hopital Pasteur, 55185, Intensive Care Unit, Nice, Provence-Alpes-Côte d'Azu, France
Hospital Clinic Universitari de Valencia, Anesthesiology and Surgical-Trauma Intensive Care , Blasco Ibañez 17 , Valencia, Valencia, Spain , 46010
Royal London Hospital, 112001, Adult Critical Care Unit, London, London, United Kingdom of Great Britain and Northern Ireland
Cambridge University, Division of Anaesthesia, Box 93 , Box 93 Addenbrooke's Hospital, , Hill's Road , CB2 0QQ , Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland , CB2 0QQ
CHUV-Lausanne University Hospita, Intensive Care Medicine , Rue du Bugnon 46 , Lausanne, Switzerland , 1011
CHUV-Lausanne University Hospita, Intensive Care Medicine, Lausanne, Switzerland
Erasmus MC, 6993, 2. Department of Intensive Care (Office H-611) and Erasmus MC Stroke Center, Erasmus Medical Center Rotterdam, Rotterdam, Zuid-Holland, Netherlands
University of Melbourne, 2281, Melbourne, Victoria, Australia
Hopital Erasme, 70496, Intensive Care , Bruxelles, Belgium
Royal Melbourne Hospital, 90134, Intensive Care Unit, Melbourne, Victoria, Australia
Intensive Care Unit, Austin Health, Heidelberg, Victoria, Australia
Issue Date: 9-Jul-2019 2019-07-09
Publication information: Journal of Neurotrauma 2019; online first: 9 July
Abstract: The optimal osmotic agent to treat intracranial hypertension in patients with severe traumatic brain injury (TBI) remains uncertain. We aimed to test whether the choice of mannitol or hypertonic saline (HTS) as early (first 96 hours) osmotherapy in these patients might be associated with a difference in mortality. We retrospectively analysed data from 2015 from 14 tertiary ICUs in Australia, UK and Europe treating severe TBI patients with intracranial pressure (ICP) monitoring, and compared mortality in those who received mannitol only versus HTS only. We performed multivariable analysis adjusting for site and illness severity (Injury Severity Score, extended IMPACT score, and mean intracranial pressure over the first 96 hours) using Cox proportional hazards regression. We collected data on 262 patients, and compared patients who received early osmotherapy with mannitol alone (n=46) with those who received HTS alone (n=46). Mannitol patients were older (median age 49.2 (19.2) versus 40.5 (16.8) years, p=0.02), with higher Injury Severity Scores (42(15.9) versus 32.1 (11.3) p=0.001)) and IMPACT-TBI predicted 6-month mortality (34.5%[23-46] versus 25% [13-38] p=0.02), but had similar APACHE-II scores, and mean and maximum intracranial pressures over the first 96 hours. The unadjusted hazard ratio for in-hospital mortality in patients receiving only mannitol was 3.35 (95% CI 1.60-7.03, p=0.001). After adjustment for key mortality predictors, the hazard ratio for in-hospital mortality in patients receiving only mannitol was 2.64 (95% CI 0.96-7.30, p=0.06). The choice of early osmotherapy in severe TBI patients may affect survival, or simply reflect clinician beliefs about their different roles, and warrants controlled investigation. Keywords osmotherapy, traumatic brain injury, mannitol, hypertonic saline, mortality.
DOI: 10.1089/neu.2019.6399
ORCID: 0000-0002-1650-8939
PubMed URL: 31286839
Type: Journal Article
Appears in Collections:Journal articles

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