Hypertonic saline vs. mannitol in the management of cerebral edema: A one year experience.

INTRODUCTION: Hypertonic saline solution (HTS) offer an attractive alternative to mannitol. The end result of HTS therapy is the reduction of cerebral edema and ICP. Use of HTS has been recently introduced in the neurocritical care unit (NCCU) in this institution. We report our initial experience using HTS with the following endpoints: 1) its efficiency in inducing a hypernatremic state 2) clinical outcome using GCS scoring 3) its safety and adverse effects. We also attempted to compare diese measures with a mannitol cohort and described the discharge disposition of all patients.

METHODS: This is a retrospective cohort study assessing the effects of hypertonic solution vs mannitol on cerebral edema and increased ICP based on hypernatremic state, GCS (Glasgow Coma Scale), and its adverse events. Analysis of 16 patients treated with 2 or 3 percent HTS infusions and 47 patients treated with mannitol for cerebral edema who were admitted at NCCU for a year were done. It included patient diagnoses, laboratory data, length of treatment, adverse effects and outcome at discharge. We compared the hypernatremic states, clinically based from Glasgow Coma Scale (GCS) and adverse effects of those patients to a contemporary cohort of patients who received mannitol as the sole form of osmotherapy.

RESULTS: Target hypernatremia (Na=l45-155 mEq/L) was achieved in eleven of the sixteen (68 percent) patients. Eight (50 percent) patients achieved the target serum sodium within the first 24 hours of HTS infusion. The median time to the target hypernatremia for the entire cohort was 1 day (maximum 5 days). GCS improved with mannitol (p=0.001) than with hypertonic saline solution (p=0.723). The adverse effects between the HTS and mannitol cohorts were not found to be significantly different. However, the discharge disposition of both study groups improved.

CONCLUSION: Hypertonic saline solution is an attractive alternative for osmotic therapy with mannitol due to its osmotic effects and lack of serious adverse events. The HTS showed an increasing trend of a hypernatremic state compared to mannito. The GCS improved with mannitol than with hypertonic saline solution overall but it should be noted that there is also a trend of improvement through time if further observation will be made. Both study groups did not show any significant adverse events. Larger, prospective, and controlled investigations are needed to be able to conclude our study endpoints.