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Multicenter Study
. 2017 Dec 28;21(1):328.
doi: 10.1186/s13054-017-1918-4.

Association between continuous hyperosmolar therapy and survival in patients with traumatic brain injury - a multicentre prospective cohort study and systematic review

Karim Asehnoune  1   2 , Sigismond Lasocki  3 , Philippe Seguin  4 , Thomas Geeraerts  5 , Pierre François Perrigault  6 , Claire Dahyot-Fizelier  7 , Catherine Paugam Burtz  8 , Fabrice Cook  9 , Dominique Demeure Dit Latte  10 , Raphael Cinotti  10 , Pierre Joachim Mahe  10 , Camille Fortuit  10 , Romain Pirracchio  11   12 , Fanny Feuillet  13 , Véronique Sébille  13   14 , Antoine Roquilly  10 ; ATLANREA group; COBI group
Collaborators, Affiliations
Multicenter Study

Association between continuous hyperosmolar therapy and survival in patients with traumatic brain injury - a multicentre prospective cohort study and systematic review

Karim Asehnoune et al. Crit Care. .

Abstract

Background: Intracranial hypertension (ICH) is a major cause of death after traumatic brain injury (TBI). Continuous hyperosmolar therapy (CHT) has been proposed for the treatment of ICH, but its effectiveness is controversial. We compared the mortality and outcomes in patients with TBI with ICH treated or not with CHT.

Methods: We included patients with TBI (Glasgow Coma Scale ≤ 12 and trauma-associated lesion on brain computed tomography (CT) scan) from the databases of the prospective multicentre trials Corti-TC, BI-VILI and ATLANREA. CHT consisted of an intravenous infusion of NaCl 20% for 24 hours or more. The primary outcome was the risk of survival at day 90, adjusted for predefined covariates and baseline differences, allowing us to reduce the bias resulting from confounding factors in observational studies. A systematic review was conducted including studies published from 1966 to December 2016.

Results: Among the 1086 included patients, 545 (51.7%) developed ICH (143 treated and 402 not treated with CHT). In patients with ICH, the relative risk of survival at day 90 with CHT was 1.43 (95% CI, 0.99-2.06, p = 0.05). The adjusted hazard ratio for survival was 1.74 (95% CI, 1.36-2.23, p < 0.001) in propensity-score-adjusted analysis. At day 90, favourable outcomes (Glasgow Outcome Scale 4-5) occurred in 45.2% of treated patients with ICH and in 35.8% of patients with ICH not treated with CHT (p = 0.06). A review of the literature including 1304 patients from eight studies suggests that CHT is associated with a reduction of in-ICU mortality (intervention, 112/474 deaths (23.6%) vs. control, 244/781 deaths (31.2%); OR 1.42 (95% CI, 1.04-1.95), p = 0.03, I 2 = 15%).

Conclusions: CHT for the treatment of posttraumatic ICH was associated with improved adjusted 90-day survival. This result was strengthened by a review of the literature.

Keywords: Brain oedema; Hyperosmolar therapy; Hypertonic; Intracranial hypertension; Saline solution; Sodium; Trauma; Traumatic brain injury.

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Conflict of interest statement

Ethics approval and consent to participate

The study protocol of this sub-study of three prospective trials was approved by an institutional review board (Comité d'Éthique de la Recherche en Anesthésie-Réanimation, CERAR#2016-01-03). Informed consent was waived owing to the non-interventional design of this study and because relatives and patients provided informed consent for the collection of medical data in the original studies.

Consent for publication

Not applicable.

Competing interests

KA received funding for himself from LFB®, Fresenius® and Baxter®. Other authors declare that they have no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Flow chart. GOS Glasgow Outcome Scale
Fig. 2
Fig. 2
Time course of the blood levels of sodium (a) and of intracranial pressure (b) in patients treated or not with continuous hyperosmolar therapy. ICH intracranial hypertension
Fig. 3
Fig. 3
Comparison of 90-day outcomes in patients with traumatic brain injury (TBI) with intracranial hypertension (ICH) treated or not with continuous hyperosmolar therapy. a Cumulative incidence curves for survival at day 90. b Glasgow Outcome Scale (GOS) at day 90 in patients with TBI with ICH treated or not with continuous hyperosmolar therapy
Fig. 4
Fig. 4
Number of patients deceased on day 28 or hospital discharge in the review of literature. M-H Mantel-Haenszel
See this image and copyright information in PMC

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