Early Induced Hypernatremia for the Prevention and Management of Brain Edema

Hospital Pablo Tobón Uribe

Overview

The purpose of this study is to estimate the effect of an early induced hypernatremia protocol (150-155 milliequivalent/L) versus normonatremia plus mannitol (135 - 145 milliequivalent/L) in terms of neurologic outcome in patients with severe traumatic brain injury managed at critical care unit.

Severe traumatic brain injury is one of the main causes of death in young people. Additionally, it is considered a public health problem because of the high prevalence of motor and cognitive dysfunction in those who survive. One of the cornerstones of management is the control of both intracranial pressure and brain edema. It is indicated to use osmotic active solutions to modulate the transit of fluids from the interstitial to the intracellular space. Not only mannitol but also hypertonic saline acts at this point. Currently there is no evidence in favor or against one of them. Mannitol has been usually recommended for intracranial pressure control in patients with brain trauma. However, others recommend hypertonic saline to achieve a serum sodium level of 160 milliequivalent/L to modulate brain edema. It is not clear if these therapies have an impact on the neurologic prognosis and how frequently adverse effects occur.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

DOUBLE

Conditions

Head Trauma

Interventions

HypernatremiaOTHER

Serum Sodium goal: 150 - 155 milliequivalent/L.

Eligibility

Sex: ALLMin age: 14 Years

Medical Language ↔ Plain English

Inclusion Criteria: 1. Patient greater than 14 years old, who suffered severe non-penetrating Brain Trauma (Glasgow Coma Scale (GCS) equal or less than 8) and a motor GCS equal or less than 5. 2. Criteria time: admitted to the Hospital in the first 24 hours of the Brain Trauma (BT) and admitted to ICU in the first 48 hours of brain trauma. 3. Tomographic evidence of brain edema (one of the following criteria: deviation from the midline, obliteration of perimesencephalic cistern or altered cortico-subcortical differentiation). Exclusion Criteria: 1. Patient with GCS 3 and bilateral mydriatic pupils and unreactive to light, in the presence of hemodynamic stability (systolic blood pressure equal or greater than 90 mmHg). 2. Patient with insipid diabetes at the ICU admission. 3. Patient with limitation of therapeutic effort. 4. Non-neurological Abbreviated Injury Score greater than 3. 5. Patient past medical history of kidney failure, liver disease or heart failure. 6. Serum sodium less than 135 or greater than 150 milliequivalent/L. 7. Pregnancy. 8. Terminal disease. 9. No authorization to be enrolled in the trial by the patient's caregiver

Outcomes

Primary Outcomes

Glasgow Outcome Scale Extended

The Extended Glasgow Outcome Scale (GOSE) is a global scale for functional outcome that rates patients into eight categories. The categories of severe disability, moderate disability and good recovery are subdivided into a lower and upper category. The scale will be used to evaluate the patient through a phone interview at 6 months of the trauma occurred. The structured interview contains nineteen specific questions which determine upper or lower levels of disability.

Time frame: 6 months

Secondary Outcomes

All-cause mortality

Mortality by any cause

Time frame: 28 - day AND 180 - day mortality

Ventilator - Free Days

Days free of mechanical ventilation at 30 days

Time frame: 30 days

Fluid balance.

Net fluid balance (input minus output) (ml) at day 1,2,3,4 y 5.

Time frame: 5 days

Acute kidney injury

Acute kidney injury (KDIGO criteria). The criteria for acute kidney injury(AKI) are based on changes in serum creatinine (SCr) and urine output. Stage I : Increase in SCr more than 1.5 times baseline, which is known or presumed to have occurred within the prior 7 days OR increase in SCr more than 0.3 mg/dL within 48 hours OR urine output \<0.5 ml/kg/h for 6-12h. Stage II : Increase in SCr between 2.0 - 2.9 times baseline, which is known or presumed to have occurred within the prior 7 days OR urine output \<0.5 ml/kg/h for more than 12 hours. Stage III : Increase more than 3.0 times baseline, which is known or presumed to have occurred within the prior 7 days OR Increase in serum creatinine to 4.0 mg/dL OR Initiation of renal-replacement therapy OR urine output \<0.3 ml/kg/h for more than 24 hours OR Anuria for more than 12 hours.

Time frame: 7 days

Data from ClinicalTrials.gov

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