Download PDF
CC BY-NC-ND 4.0 · J Neuroanaesth Crit Care 2018; 05(03): 164-167
DOI: 10.1055/s-0038-1670024
Original Article
Indian Society of Neuroanaesthesiology and Critical Care

Urinary Sodium Loss following Hypertonic Saline Administration Curtails its Superior Osmolar Effect in Comparison to Mannitol in Severe Traumatic Brain Injury: A Secondary Analysis of a Randomized Controlled Trial

Aniruddha Tekkatte Jagannatha
1   Department of Neurosurgery, MS Ramaiah Medical College, Bengaluru, India
,
Kamath Sriganesh
2   Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
,
Bhagavatula Indira Devi
3   Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
,
Ganne Sesha Umamaheswara Rao
2   Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
› Author Affiliations
Further Information

Publication History

Received: 05 June 2018

Accepted after revision: 26 July 2018

Publication Date:
14 September 2018 (online)

   Permissions and Reprints

Abstract

Background Mannitol and hypertonic saline (HTS) are used as boluses during episodes of raised intracranial pressure (ICP) in severe traumatic brain injury (TBI). We recently demonstrated that ICP reduction and neurological outcomes are similar with mannitol and HTS in TBI. In the current post hoc analysis, we hypothesized that this lack of difference between mannitol and HTS is due to increased urinary sodium losses after HTS.

Methods In this post hoc analysis of our earlier randomized controlled trial, we analyzed serum and urine osmolarity and sodium levels in 38 patients with severe TBI over 6 days. Equiosmolar boluses of mannitol and HTS were administered whenever ICP increased above 20 mm Hg. Seven hundred sixty samples each of serum sodium, urine sodium, serum osmolarity, and urine osmolarity were analyzed during this period.

Results Three hundred and one and 187 boluses of mannitol and HTS, respectively, were required to maintain ICP below 20 mm Hg. The urinary osmolarity was similar between mannitol and HTS groups (p = 0.63). The urinary sodium excretion was significantly higher in HTS group compared with mannitol group (p = 0.002). Serum sodium and osmolarity values were similar between mannitol and HTS groups (p = 0.16 and 0.31, respectively). There was no difference in the mean ICP between the groups (p = 0.31).

Conclusion Increased urinary sodium loss after HTS contributes to its lack of superiority over mannitol in controlling raised ICP.

Keywords

traumatic brain injury - mannitol - hypertonic saline - urine sodium
 

  • References

  • 1 Huang SJ, Chang L, Han YY, Lee YC, Tu YK. Efficacy and safety of hypertonic saline solutions in the treatment of severe head injury. Surg Neurol 2006; 65 (06) 539-546 discussion 546
    CrossrefPubMedGoogle Scholar
  • 2 Jagannatha AT, Sriganesh K, Devi BI, Rao GSU. An equiosmolar study on early intracranial physiology and long term outcome in severe traumatic brain injury comparing mannitol and hypertonic saline. J Clin Neurosci 2016; 27: 68-73
    CrossrefPubMedGoogle Scholar
  • 3 Boone MD, Oren-Grinberg A, Robinson TM, Chen CC, Kasper EM. Mannitol or hypertonic saline in the setting of traumatic brain injury: what have we learned?. Surg Neurol Int 2015; 6: 177
    PubMedGoogle Scholar
  • 4 Burgess S, Abu-Laban RB, Slavik RS, Vu EN, Zed PJ. A systematic review of randomized controlled trials comparing hypertonic sodium solutions and mannitol for traumatic brain injury: implications for emergency department management. Ann Pharmacother 2016; 50 (04) 291-300
    CrossrefPubMedGoogle Scholar
  • 5 Cottier PT, Weller JM, Hoobler SW. Effect of an intravenous sodium chloride load on renal hemodynamics and electrolyte excretion in essential hypertension. Circulation 1958; 17 (04) Part 2 750-760
    CrossrefPubMedGoogle Scholar
  • 6 Baldwin D, Kahana EM, Clarke RW. Renal excretion of sodium and potassium in the dog. Am J Physiol 1950; 162 (03) 655-664
    PubMedGoogle Scholar
  • 7 Selkurt EE, Post RS. Renal clearance of sodium in the dog: effect of increasing sodium load on reabsorptive mechanism. Am J Physiol 1950; 162 (03) 639-648
    PubMedGoogle Scholar
  • 8 Goldsmith C, Rector Jr FC, Seldin DW. Evidence for a direct effect of serum sodium concentration on sodium reabsorption. J Clin Invest 1962; 41: 850-859
    CrossrefPubMedGoogle Scholar
  • 9 Roquilly A, Mahe PJ, Latte DD. et al. Continuous controlled-infusion of hypertonic saline solution in traumatic brain-injured patients: a 9-year retrospective study. Crit Care 2011; 15 (05) R260
    CrossrefPubMedGoogle Scholar
  • 10 Tan SK, Kolmodin L, Sekhon MS. et al. The effect of continuous hypertonic saline infusion and hypernatremia on mortality in patients with severe traumatic brain injury: a retrospective cohort study. Can J Anaesth 2016; 63 (06) 664-673
    CrossrefPubMedGoogle Scholar
  • 11 Galton C, Deem S, Yanez ND. et al. Open-label randomized trial of the safety and efficacy of a single dose conivaptan to raise serum sodium in patients with traumatic brain injury. Neurocrit Care 2011; 14 (03) 354-360
    CrossrefPubMedGoogle Scholar
  • 12 Askar A, Tarif N. Cerebral salt wasting in a patient with head trauma: management with saline hydration and fludrocortisone. Saudi J Kidney Dis Transpl 2007; 18 (01) 95-99
    PubMedGoogle Scholar