Kumaraguru, D (2011) 3% Saline Versus Mannitol in Treatment of Cerebral Edema in Children. Masters thesis, Madurai Medical College, Madurai.
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Abstract
INTRODUCTION: Intracranial hypertension is a common feature of many illness treated in PICU. The early signs and symptoms of intracranial hypertension tend to be nonspecific. The classic Cushings triad of bradycardia, hypertension, and apnea occurs late and often not manifest fully in children. Most of our understandings and approach to treatment is based on studies of patients with traumatic brain injuries. Whether those concepts are directly relevant to the pathophysiologic processes involved in more global CNS injuries such as hypoxia, infection and metabolic disorders, remain a matter of debate. Within constraints of a closed skull, an enlargement of brain tissue (cerebral edema), an increased volume of CSF, or an increased volume of blood or the presence of a space-occupying lesion (SOL) such as a tumour or an abscess will initially reduce the size of the other compartments and later increase intracranial pressure, once the compensatory mechanisms fail. AIM OF THE STUDY: To study the effectiveness of 3% saline as an antiedema measure in children admitted with cerebral edema in the pediatric intensive care unit of a tertiary care children hospital in a developing country. DISCUSSION: The earliest description in the literature of the use of osmotic agents dates back to 1919 [18]. While studying the transport of salt solutions into the neuraxis, Weed and McKibben observed that intravenous administration of a concentrated salt solution resulted in an inability to withdraw CSF from the lumbar cistern due to a collapse of the thecal sac. This serendipitous observation was followed by an elegant set of experiments in an animal model in which they demonstrated (under direct visualization via a craniotomy) regression of the brain away from the cranial vault with intravenous infusion of hypertonic saline solutions and herniation of brain tissue with administration of hypotonic fluids. This set of observations has formed the basis for osmotherapy. Concentrated urea was the first agent to be used clinically as an osmotic agent. [8,9,19]. Its use was short-lived and is of historic interest only because of several untoward side effects (nausea, vomiting, diarrhea, and coagulopathy) [19]. The interest in elevating plasma oncotic pressure as a strategy to ameliorate cerebral edema with the use of concentrated human plasma proteins, which appeared briefly in 1940, was short-lived due to several concerns, including cost, short half-life, cardiopulmonary effects, and allergic reactions [19]. Glycerol was possibly the second osmotic agent to be 43 used clinically. Mannitol, an alcohol derivative of simple sugar mannose, was introduced in 1960 and has since remained the major osmotic agent of choice in clinical practice [8,9,19]. Its long duration of action (4–6 hours) and relative stability in solution have enhanced its use over the years. The extra osmotic properties of mannitol have been studied extensively and may provide additional beneficial effects in brain injury, including decreases in blood viscosity, resulting in increases in rCBF and CPP, and a resultant cerebral vasoconstriction leading to decreased CBV,[20,21] free radical scavenging,[22] and inhibition of apoptosis [23]. Renewed interest in hypertonic saline solutions reappeared in the 1980s, when they were used in small-volume resuscitation in patients experiencing hemorrhagic shock. [8,9]. These studies demonstrated that prehospital restoration of intravascular volume improved morbidity and mortality rates and physiological parameters (such as systemic blood pressure, cardiac index, and tissue perfusion) in this subset of patients . In subsequent studies, cerebral effects of these solutions were investigated in well-controlled experimental studies in animal models of acute brain injury. Like mannitol, hypertonic saline also possesses unique extraosmotic properties, including modulation of CSF production and resorption and accentuation of tissue oxygen delivery. The use of hypertonic saline solution in the treatment of cerebral edema and elevated ICP in the clinical setting is largely based on an extension of laboratory-based research, a few prospective studies in humans, and anecdotal case reports. The first report to demonstrate the efficacy of hypertonic saline in patients with TBI [25] involved two patients with elevated ICP refractory to mannitol who were treated successfully with a single intravenous bolus of 30% saline, after which ICP decreased and systemic perfusion improved. Continuous intravenous infusion of 2.5 and 5.4% hypertonic saline enhanced CPP and improved somatosensory evoked potentials after brainstem trauma [26]. Likewise, in an uncontrolled, nonrandomized study, [27] reductions in ICP were noted with the use of 7.5% hypertonic saline treatment following TBI. CONCLUSION: To conclude, in the treatment of cerebral edema of infectious, metabolic and non traumatic origin in children, 3%saline is as effective and safe as mannitol.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | 3% Saline Versus Mannitol ; Treatment ; Cerebral Edema ; Children |
| Subjects: | MEDICAL > Paediatrics |
| Depositing User: | Ravindran C |
| Date Deposited: | 13 Apr 2018 10:48 |
| Last Modified: | 13 Apr 2018 10:48 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/6990 |
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