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Steve-

A couple of issues with translation of U/S data from Adult to Peds and one of them is measurements.

As you know the reliability of IVC diameter for fluid status (not to mention fluid responsiveness) is itself debatable. Now to be able to tell whether an 8 y.o child's IVC is plump or under-filled is even more contentious. 

Comparison of measurement of optic nerve root sheath diameter (for an adult, should be less than 5 mm at 3 mm from retina) btwn an 25 y.o. and a 10 mo old are fraught with the same limitations. Very few peds studies available looking at ONSD (see below).

We (ED/Trauma) use HTS almost universally (at the doses mentioned). Nsx usually opts for it whenever pt is hypotensive or has the potential to be otherwise they prefer mannitol (I think more b/c of familiarity).

Joe

---------------------------------------------
Joe Nemeth MD CCFP (Emergency Medicine)
Assistant Professor
Pediatrics, Family Medicine 
Director
Department of Emergency Medicine
Montreal General Hospital
McGill University Health Center


Detection of raised intracranial pressure by ultrasound measurement of optic nerve sheath diameter in African children.
  Beare NA, Kampondeni S, Glover SJ, Molyneux E, Taylor TE, Harding SP, Molyneux ME
Tropical Medicine & International Health : TM & IH [2008, 13(11):1400-1404]

________________________________________
From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] on behalf of Steve Socransky [[log in to unmask]]
Sent: Thursday, February 21, 2013 1:33 PM
To: [log in to unmask]
Subject: Re: mannitol and CHI

I'm more from the adult world and only use Mannitol if I use anything.  I make my decision partly using point-of-care ultrasound.  I use Mannitol only if the IVC does not show evidence of hypovolemia.  If there's evidence of hypovolemia I avoid mannitol with the thinking that the cerebral blood flow will benefit more from IV fluids.  I also won't usually give mannitol if there is no evidence of raised ICP based on measurement of the optic nerve shadow.  I'm not sure though what normal optic nerve diameter would be based on age.  Does anyone know if there is data in the peds literature for the optic nerve?
Steve Socransky
Sudbury, Ontario

Sent from my iPhone

On 2013-02-21, at 12:35 PM, Daniel Thimann <[log in to unmask]> wrote:

> I am also interested in this topic since I do not believe there is a standard of care. There new guidelines, ie revision to the previous guidelines for traumatic brain injury in pediatrics also reflects the same fact towards preference of 3% saline in a dose of 6-10 ml/kg over mannitol. Mannitol could be associated with hypotension secondary to increase in urine output and hypotension is not favored in TBI. Also, if disruption of the Blood brain barrier occurs, there is a theoretical risk that mannitol could leach out to brain or the brain bleed and increase the osmotic pressure inside the brain leading to worsening cerebral edema.
> I have also read that in some papers mannitol may have increase morbidity and worse outcomes. These guidelines are pretty extensive if you have time to read them. I as a fellow do prefer 3% saline over mannitol, in our institution we currently use a dose of 3-5 ml/kg and we usually infuse it over 15 minutes unless it is a critical case we push it. It may be interesting to know what other doses people use and how they use it.
>
> Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition.
> Pediatr Crit Care Med. 2012 Mar;13(2):252.
>
> Thank you
>
> Daniel Thimann MD PGY-5
> Pediatric Emergency Medicine Fellow
>
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For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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The URL for the PED-EM-L Web Page is:
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