Early osmotherapy in severe traumatic brain injury: An international multicenter study

James R. Anstey, Fabio S. Taccone, Andrew A. Udy, Giuseppe Citerio, Jacques Duranteau, Carole Ichai, Rafael Badenes, John R. Prowle, Ari Ercole, Mauro Oddo, Antoine G. Schneider, Mathieu Van Der Jagt, Stefan Wolf, Raimund Helbok, David W. Nelson, Marius B. Skrifvars, Anatole Harrois, Jeffrey Presneill, D. Jamie Cooper, Michael BaileyRinaldo Bellomo, on behalf of The TBI Collaborative

Research output: Contribution to journalArticleResearchpeer-review

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 h) osmotherapy in these patients might be associated with a difference in mortality. We retrospectively analyzed data from 2015 from 14 tertiary intensive care units (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 multi-variable analysis adjusting for site and illness severity (Injury Severity Score, extended IMPACT score, and mean ICP over the first 96 h) 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) vs. 40.5 (16.8) years; p = 0.02), with higher Injury Severity Scores (42 (15.9) vs. 32.1 [11.3]; p = 0.001), and IMPACT-TBI predicted 6-month mortality (34.5% [23-46] vs. 25% [13-38]; p = 0.02), but had similar APACHE-II scores, and mean and maximum ICPs over the first 96 h. The unadjusted hazard ratio for in-hospital mortality in patients receiving only mannitol was 3.35 (95% confidence interval [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.

Original languageEnglish
Pages (from-to)178-184
Number of pages7
JournalJournal of Neurotrauma
Volume37
Issue number1
DOIs
Publication statusPublished - 1 Jan 2020

Keywords

  • hypertonic saline
  • mannitol
  • mortality
  • osmotherapy
  • traumatic brain injury

Cite this

Anstey, J. R., Taccone, F. S., Udy, A. A., Citerio, G., Duranteau, J., Ichai, C., ... on behalf of The TBI Collaborative (2020). Early osmotherapy in severe traumatic brain injury: An international multicenter study. Journal of Neurotrauma, 37(1), 178-184. https://doi.org/10.1089/neu.2019.6399
Anstey, James R. ; Taccone, Fabio S. ; Udy, Andrew A. ; Citerio, Giuseppe ; Duranteau, Jacques ; Ichai, Carole ; Badenes, Rafael ; Prowle, John R. ; Ercole, Ari ; Oddo, Mauro ; Schneider, Antoine G. ; Van Der Jagt, Mathieu ; Wolf, Stefan ; Helbok, Raimund ; Nelson, David W. ; Skrifvars, Marius B. ; Harrois, Anatole ; Presneill, Jeffrey ; Cooper, D. Jamie ; Bailey, Michael ; Bellomo, Rinaldo ; on behalf of The TBI Collaborative. / Early osmotherapy in severe traumatic brain injury : An international multicenter study. In: Journal of Neurotrauma. 2020 ; Vol. 37, No. 1. pp. 178-184.
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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 h) osmotherapy in these patients might be associated with a difference in mortality. We retrospectively analyzed data from 2015 from 14 tertiary intensive care units (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 multi-variable analysis adjusting for site and illness severity (Injury Severity Score, extended IMPACT score, and mean ICP over the first 96 h) 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) vs. 40.5 (16.8) years; p = 0.02), with higher Injury Severity Scores (42 (15.9) vs. 32.1 [11.3]; p = 0.001), and IMPACT-TBI predicted 6-month mortality (34.5{\%} [23-46] vs. 25{\%} [13-38]; p = 0.02), but had similar APACHE-II scores, and mean and maximum ICPs over the first 96 h. The unadjusted hazard ratio for in-hospital mortality in patients receiving only mannitol was 3.35 (95{\%} confidence interval [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.",
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Anstey, JR, Taccone, FS, Udy, AA, Citerio, G, Duranteau, J, Ichai, C, Badenes, R, Prowle, JR, Ercole, A, Oddo, M, Schneider, AG, Van Der Jagt, M, Wolf, S, Helbok, R, Nelson, DW, Skrifvars, MB, Harrois, A, Presneill, J, Cooper, DJ, Bailey, M, Bellomo, R & on behalf of The TBI Collaborative 2020, 'Early osmotherapy in severe traumatic brain injury: An international multicenter study', Journal of Neurotrauma, vol. 37, no. 1, pp. 178-184. https://doi.org/10.1089/neu.2019.6399

Early osmotherapy in severe traumatic brain injury : An international multicenter study. / Anstey, James R.; Taccone, Fabio S.; Udy, Andrew A.; Citerio, Giuseppe; Duranteau, Jacques; Ichai, Carole; Badenes, Rafael; Prowle, John R.; Ercole, Ari; Oddo, Mauro; Schneider, Antoine G.; Van Der Jagt, Mathieu; Wolf, Stefan; Helbok, Raimund; Nelson, David W.; Skrifvars, Marius B.; Harrois, Anatole; Presneill, Jeffrey; Cooper, D. Jamie; Bailey, Michael; Bellomo, Rinaldo; on behalf of The TBI Collaborative.

In: Journal of Neurotrauma, Vol. 37, No. 1, 01.01.2020, p. 178-184.

Research output: Contribution to journalArticleResearchpeer-review

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T1 - Early osmotherapy in severe traumatic brain injury

T2 - An international multicenter study

AU - Anstey, James R.

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AU - Udy, Andrew A.

AU - Citerio, Giuseppe

AU - Duranteau, Jacques

AU - Ichai, Carole

AU - Badenes, Rafael

AU - Prowle, John R.

AU - Ercole, Ari

AU - Oddo, Mauro

AU - Schneider, Antoine G.

AU - Van Der Jagt, Mathieu

AU - Wolf, Stefan

AU - Helbok, Raimund

AU - Nelson, David W.

AU - Skrifvars, Marius B.

AU - Harrois, Anatole

AU - Presneill, Jeffrey

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AU - Bailey, Michael

AU - Bellomo, Rinaldo

AU - on behalf of The TBI Collaborative

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N2 - 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 h) osmotherapy in these patients might be associated with a difference in mortality. We retrospectively analyzed data from 2015 from 14 tertiary intensive care units (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 multi-variable analysis adjusting for site and illness severity (Injury Severity Score, extended IMPACT score, and mean ICP over the first 96 h) 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) vs. 40.5 (16.8) years; p = 0.02), with higher Injury Severity Scores (42 (15.9) vs. 32.1 [11.3]; p = 0.001), and IMPACT-TBI predicted 6-month mortality (34.5% [23-46] vs. 25% [13-38]; p = 0.02), but had similar APACHE-II scores, and mean and maximum ICPs over the first 96 h. The unadjusted hazard ratio for in-hospital mortality in patients receiving only mannitol was 3.35 (95% confidence interval [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.

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