Response to Drs. Quintard, et al.
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RESPONSE TO LETTER TO THE EDITOR
Response to Drs. Quintard, et al. Aaron M. Cook1* and Lori Shutter2 © 2020 Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society
Drs. Quintard, et al. we thank you for your attentive reading and consideration of the Neurocritical Care Society Cerebral Edema treatment guidelines [1]. Your letter brings up the point that our writing group debated and deliberated over the most. We agree that the literature in this area is not definitive and that variability exists across the studies and meta-analyses regarding the effect of hypertonic sodium solutions (HTS) and mannitol on cerebral edema or intracranial pressure. The recommendation in the guideline for patients with traumatic brain injury is based on low-level evidence, and it is rated as ‘conditional.’ This designation is typically reserved for statements that do not apply to all patients and that potential desirable effects of adherence to this recommendation probably outweigh any undesirable effects. This also indicates that the panel was not confident about these trade-offs due to an absence of high-quality data, imprecise estimates of benefit/harm or variation in how different individuals might value the outcome [2]. While some studies used formulations of HTS combined with colloid (dextran or hetastarch) as Dr. Quintard, et al. state, numerous studies used solely crystalloid HTS and suggested HTS may be preferable to mannitol [3–9]. The conditional designation of the recommendation essentially makes our statement: ‘HTS is suitable as the primary osmotherapy agent, but not for all patients with traumatic brain injury and with the proviso that there is a lack of high-quality data and some variability in the results of the published literature which limits the confidence in this statement. There may be conditions or circumstances where another agent is preferable.’ We also specifically state that neither osmotherapy agent should be used with the expectation that neurological outcomes will be improved in this population.
*Correspondence: [email protected] 1 UKHealthcare, University of Kentucky College of Pharmacy, Lexington, KY, USA Full list of author information is available at the end of the article
The conditional recommendation refers specifically to the impact on treatment of cerebral edema or elevated intracranial pressure, not neurological outcome or mortality. We disagree with Dr. Quintard, et al. that the paired statements suggesting HTS was at least as safe and effective as mannitol and that mannitol is also a safe and effective option are contradictory. In this situation, there is no definitive ‘winner’ and ‘loser’ in these studies, rather just Option A and Option B. The published literature, and years of practical clinical experience with both agents, suggests that either option is reasonable in most patients requiring treatment for cerebral edema or intracranial pressure elevations. Thus, the writing group also wanted to ensure that mannitol was mentioned as a viable opt
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