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Intra Cranial Pressure
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Traumatic Brain Injury
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Traumatic Brain Injury
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Brain edema
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I
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Hypertonic Saline VS Manitol
VS
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Hypertonic Saline
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Journal Reading
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Introduction
Traumatic brain injury (TBI) is the leading
cause of morbidity and mortality in young
adults
When treating TBI, optimal intracranial
pressure (ICP) control (< 20mmHg) and an
adequate cerebral perfusion pressure of 50 to
70 mmHg are goals associated with lowermortality
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While mannitol has long been a mainstay of
ICP management, the use of hypertonic saline
(HTS) has more recently gained increasing
support.
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Material and methods
Study design : Retrospective
Sample : All consecutive patients admitted to
the Regional Medical Center at Memphis for
TBI between January 2006 and March 2011
who received at least one dose of HTS
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Patient Treatment
Patient with severe TBIICP Monitor
ICP and CPP recorded hourly
Monitoring the serum sodium concentrationevery 6 hours
Using HTS to raise it above 145 mEq/l
Most patients received 150 ml of 3% HTSintravenously over 2
hours
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Outcome
Primary outcome : the relationship between
serum sodium and the corresponding
maximum ICP
Secondary outcome : the relationship
between the serum sodium and the number
of therapeutic interventions for increased ICP
management, and the acute effect of HTSboluses on ICP.
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Methods
Each serum sodium value was matched with
the highest corresponding ICP
The change in serum sodium was matched
with the change in ICP
To account for interpatient variability, serum
sodium and the corresponding maximum ICP
for each individual patient were also
determined.
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Methods for secondary outcome
patients were divided into three groups basedon their mean daily
serum sodium: < 145mEq/l, 145 to 155 mEq/l, and > 155
mEq/l.
The following treatments were included as anintervention:
HTS infusion
Mannitol infusion, sedation or analgesia given by
continuous infusion, neuromuscular blocker (NMB) infusion,
pentobarbital
infusion, or acute hyperventilation
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Statistical Analysis
Continous variableT-test for normallydistributed variable,
Wilcoxon test for non-normally distributed variables.
Proportions were compared using the chi-squared test.
Linear regression was used to evaluate therelationship between
serum sodium levels and
corresponding maximum ICP Multiple pairwise comparisons were
made using
Dunns method.
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Result
A total of 81 patients with TBI were enrolledinto the study
Sixty-eight patients (84%) received 3% sodium
chloride boluses only. The remaining patientsreceived a
combination of 3% and 7.5% sodiumchloride boluses, and/or
continuous infusions of3% sodium chloride.
A total of 1,230 serum sodium values (sodiumrange, 118 to 174
mEq/l) and 7,483 ICP values(ICP range, 0 to 159 mmHg) were
collected
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Baseline demographic and clinical
characteristic
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Patients
serum sodium concentrations and their corresponding
maximum ICP
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Correlation between serum sodium
and ICP
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HTS Bolus
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Strengths and limitations
Retrospectivelack of control group
it was not possible to find a control group
that did not receive HTS
The inability to relate the time of
neurosurgical interventions is problematic due
to the effect such procedures could have on
ICP
StrengthLarge sample
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Conclussion
Serum sodium concentrations did not
correlate with ICP values. These results
warrant further evaluation and possible
reassessment of sodium goals for ICPmanagement in patients with
TBI.
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KEY message
Serum sodium values do not correlate well with
ICP in patients with TBI treated with HTS.
Achieving serum sodium values between 145 and
155 mEq/l may decrease the number of daily
interventions
required to manage elevated ICP.
HTS boluses did not significantly decrease ICP
overall.
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