Hypertonic saline after traumatic brain injury: why not?

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Hypertonic saline after traumatic brain
injurywhy not?

• Lt-Colonel H. BORET, Major A. MONTCRIOL,
  Lt-Colonel P. RAMIARA,
• Lt-Colonel E. MEAUDRE
• Intensive Care Unit
• Sainte Anne Military Teaching Hospital
• TOULON - France

boret.henry_at_neuf.fr
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• Irak 2008
• TBI 20 of the US troops (concussions)
• 242 millions for brain injuries
• Associated Press March 2009

Battlefield
Neurosurgeon
Battlefield doctor
What can we do to avoid secondary brain damages?
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MannitolYes

• The most
• Classical
• Studied (30 years)
• Recommended

Bratton J Neurotrauma - 2007
Mannitol, not HS, was the only osmotherapy 
 officially  recommended in 2007
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MannitolYes ...
Same osmotic load
Mannitol 1 g/kg
Personnal data
Francony Crit Care Med - 2008
Mannitol is effective to decrease ICHT
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Mannitol but
Mannitol
PtiO2
Oddo JNNP - 2009
Sakowitz J Trauma - 2007
No oxygenation improvement compared to HS
PitO2 - normal 35 mm Hg - Ischemic threshold lt
10-15 mm Hg
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Mannitol
Hypertonic saline
Soustiel Brain Research - 2006
HS better reduces neuroinflammatory response near
the contusion in rats than mannitol
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Mannitol but
Effect of HS (control) vs mannitol (treatment) on
mortality after TBI
 Mannitol () may have detrimental effect on
mortality when compared to hypertonic saline. 
Wakaï Cochrane Database - 2007
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First conclusion
Even if still controversial, there are some
research and clinical arguments to promote
hypertonic saline vs mannitol in traumatic brain
injury
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Other arguments for battlefield medicine
Velasco Am J Physiol - 1980
Hypertonic saline, not mannitol, is used in case
of hemorrhagic shock (small volume ressuscitation)
Burgess Textbook of military medicine
Kreimeier Acta Anaesth Scand - 2002
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Other arguments for battlefield medicine
Wade J Trauma - 1997
Discharge survival among brain injured and
hypotensive patients comparing standard of care
(Lactate Ringer) vs hypertonic saline 6 studies -
223 patients
Hypertonic saline is beneficial in case of TBI
associated to hypotension
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Other arguments for battlefield medicine
Battlefield, TBI, 80 kg

• Mannitol 20
• 1 g/kg 80 g 400 mL
• Isotonic saline (compensation of urinary losses)
  800 mL

• Hypertonic saline 7.5
• 2 mL/kg 160 mL

160 mL
1,200 mL
Utilization of HS vs mannitol requires less
transported fluids
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Second conclusion
HS is superior to mannitol for battlefield
medicine
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Hypertonic saline to go further

• First solution mortality study
• Whole mortality (including lt 48 h mortality) 40
  /-15
• Hypothesis mortality reduction with HS 5
• Sample size 286 patients

• Second solution physiopathological study
  whats going on into the brain parenchyma?
• Oxygenation PtiO2
• Metabolism cerebral microdialysis

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PtiO2
PtiO2
CPP
Cerebral microdialysis
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Our study

• To prove non-inferiority of HS vs mannitol on
  brain metabolism
• Sample size 30 patients
• 3 patients included
• 15 mannitol (1 g/kg), 15 HS 7.5 (2 mL/kg)
• Same osmotic load
• Main objective effects on lactate/pyruvate
  ratio (redox potential)
• Secondary objectives effects on ICP, PtiO2,
  cerebral glucose

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Conclusion
ICP reduction Improved oxygenation Effects on neuroinflammatory response Haemodynamic benefit Limited volume
Mannitol Yes No Limited No No
HS Yes Yes Yes Yes Yes
So, hypertonic saline after TBI why not yet?
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Questions?
Thank you