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Abstract：
The optimal osmotic agent to treat intracranial hypertension in patients with severe traumatic brain injury (TBI) remains uncertain. We aimed to test whether the choice of mannitol or hypertonic saline (HTS) as early (first 96 h) osmotherapy in these patients might be associated with a difference in mortality. We retrospectively analyzed data from 2015 from 14 tertiary intensive care units (ICUs) in Australia, UK, and Europe treating severe TBI patients with intracranial pressure (ICP) monitoring and compared mortality in those who received mannitol only versus HTS only. We performed multi-variable analysis adjusting for site and illness severity (Injury Severity Score, extended IMPACT score, and mean ICP over the first 96 h) using Cox proportional hazards regression. We collected data on 262 patients and compared patients who received early osmotherapy with mannitol alone (n = 46) with those who received HTS alone (n = 46). Mannitol patients were older (median age, 49.2 (19.2) vs. 40.5 (16.8) years; p = 0.02), with higher Injury Severity Scores (42 (15.9) vs. 32.1 [11.3]; p = 0.001), and IMPACT-TBI predicted 6-month mortality (34.5% [23-46] vs. 25% [13-38]; p = 0.02), but had similar APACHE-II scores, and mean and maximum ICPs over the first 96 h. The unadjusted hazard ratio for in-hospital mortality in patients receiving only mannitol was 3.35 (95% confidence interval [CI], 1.60-7.03; p = 0.001). After adjustment for key mortality predictors, the hazard ratio for in-hospital mortality in patients receiving only mannitol was 2.64 (95% CI, 0.96-7.30; p = 0.06). The choice of early osmotherapy in severe TBI patients may affect survival, or simply reflect clinician beliefs about their different roles, and warrants controlled investigation.
摘要：
治疗重型颅脑损伤（TBI）患者颅内高压的最佳渗透剂仍不确定。我们旨在测试这些患者早期（前96小时）渗透治疗选择甘露醇或高渗盐水（HTS）是否与死亡率差异有关。我们回顾性分析了2015年来自澳大利亚14个三级重症监护病房（ICU）的数据，英国,和欧洲对严重TBI患者进行颅内压（ICP）监测，并比较了仅接受甘露醇与仅接受HTS的死亡率。我们进行了多变量分析，调整了部位和疾病严重程度(损伤严重程度评分，扩展的影响评分，和前96小时的平均ICP)使用Cox比例风险回归。我们收集了262例患者的数据，并比较了单独接受甘露醇早期渗透治疗的患者（n=46）和单独接受HTS的患者（n=46）。甘露醇患者年龄较大（中位年龄，49.2（19.2）vs.40.5(16.8)年；p=0.02)，受伤严重程度得分较高（42（15.9）与32.1[11.3]；p=0.001)，IMPACT-TBI预测的6个月死亡率（34.5%[23-46]与25%[13-38]；p=0.02)，但APACHE-II评分相似,以及最初96小时内的平均和最大ICPs。仅接受甘露醇的患者住院死亡率的未调整风险比为3.35（95％置信区间[CI]，1.60-7.03；p=0.001）。在对关键死亡率预测因子进行调整后，仅接受甘露醇治疗的患者院内死亡率的风险比为2.64(95%CI,0.96~7.30;p=0.06).严重TBI患者早期渗透治疗的选择可能会影响生存率，或者只是反映临床医生对他们不同角色的信念，并保证进行控制调查。
