Hypertonic saline after traumatic brain injury: why not?

1. Hypertonic saline after traumatic brain injury:why 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@neuf.fr

2. 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?

3. MannitolYes… The most: Classical Studied (30 years) Recommended Bratton – J Neurotrauma - 2007 Mannitol, not HS, was the only osmotherapy  « officially » recommended in 2007

4. MannitolYes ... Same osmotic load Mannitol 1 g/kg Personnal data Francony – Crit Care Med - 2008 Mannitol is effective to decrease ICHT

5. Mannitol… but Mannitol PtiO2 Sakowitz – J Trauma - 2007 Oddo – JNNP - 2009 No oxygenation improvement compared to HS PitO2: - normal = 35 mm Hg - Ischemic threshold < 10-15 mm Hg

6. Mannitol Hypertonic saline Soustiel – Brain Research - 2006 HS better reduces neuroinflammatory response near the contusion in rats than mannitol

7. 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

8. First conclusion Even if still controversial, there are some research and clinical arguments to promote hypertonic saline vs mannitol in traumatic brain injury

9. 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

10. 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

11. Other arguments for battlefield medicine 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 Battlefield, TBI, 80 kg 160 mL 1,200 mL Utilization of HS vs mannitol requires less transported fluids

12. Second conclusion HS is superior to mannitol for battlefield medicine

13. Hypertonic saline: to go further First solution : mortality study Whole mortality (including < 48 h mortality) = 40 +/-15% Hypothesis : mortality reduction with HS = 5% Sample size = 286 patients Second solution : physiopathologicalstudy: what’sgoing on into the brainparenchyma? Oxygenation = PtiO2 Metabolism = cerebralmicrodialysis

14. PtiO2 PtiO2 CPP Cerebral microdialysis

15. 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

16. Conclusion So, hypertonic saline after TBI… why not… yet?

17. Questions? Thank you