Osmotherapy: Use Among Neurointensivists
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ORIGINAL ARTICLE
Osmotherapy: Use Among Neurointensivists Angela N. Hays • Christos Lazaridis • Ron Neyens Joyce Nicholas • Sarah Gay • Julio A. Chalela
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Published online: 14 December 2010 Ó Springer Science+Business Media, LLC 2010
Abstract Background Cerebral edema and raised intracranial pressure are common problems in neurological intensive care. Osmotherapy, typically using mannitol or hypertonic saline (HTS), has become one of the first-line interventions. However, the literature on the use of these agents is heterogeneous and lacking in class I studies. The authors hypothesized that clinical practice would reflect this heterogeneity with respect to choice of agent, dosing strategy, and methods for monitoring therapy. Methods An on-line survey was administered by e-mail to members of the Neurocritical Care Society. Multiplechoice questions regarding use of mannitol and HTS were employed to gain insight into clinician practices. Results A total of 295 responses were received, 79.7% of which were from physicians. The majority (89.9%) reported using osmotherapy as needed for intracranial hypertension, though a minority reported initiating treatment prophylactically. Practitioners were fairly evenly split between those who preferred HTS (54.9%) and those who preferred mannitol (45.1%), with some respondents reserving HTS for patients with refractory intracranial hypertension. Respondents who preferred HTS were more likely to endorse prophylactic administration. Preferred dosing regimens for both agents varied considerably, as did monitoring parameters.
A. N. Hays (&) Department of the Neurosciences, Division of Adult Neurology, Medical University of South Carolina, Charleston, SC, USA e-mail: [email protected] C. Lazaridis R. Neyens J. Nicholas S. Gay J. A. Chalela Medical University of South Carolina, Charleston, SC, USA
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Conclusions Treatment of cerebral edema using osmotically active substances varies considerably between practitioners. This variation could hamper efforts to design and implement multicenter trials in neurocritical care. Keywords Osmotherapy Cerebral edema Intracranial pressure Intracranial hypertension Traumatic brain injury Hypertonic saline Mannitol Survey Neurocritical care
Introduction Cerebral edema is a pervasive problem in neurocritical care. It is an inevitable consequence of acute brain injury, including ischemic stroke, intracranial hemorrhage (ICH), traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), CNS infections, and intracranial neoplasms. It is widely recognized as one of the underlying causes of secondary brain injury contributing to poor patient outcome in many of these disease states. Unchecked brain edema has potentially devastating consequences, including intracranial hypertension, cerebral ischemia, herniation, and eventual progression to death. Consequently, early recognition and treatment are critical. Use of osmotically active substances is the mainstay of therapy for cerebral edema, with or without associated intracranial hypert
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