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Absence of evidence does not mean evidence of absence.

1800 patients total in 11 small studies in a systematic review. We clearly need a large, multi-insitutional RCT on this.

In the meantime, I will continue to use it based on

1. Biologic plausibility,
2. Low risk of harm, and
3. Low cost.

Anecdotally, my colleague had an 11 y.o. with ruptured AVM 3 nights ago. Every time they administered 3% NS she improved her mental status. They were trying to decide whether or not to intubate her and place a drain but the hypertonic saline improved her each time and they did not end up intubating her or placing the drain.

JMHO.

Jim

James Chamberlain
Division Chief, Emergency Medicine
Children’s National Health System
(202) 476-4177


-----Original Message-----
From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Michael Falk
Sent: Tuesday, August 01, 2017 4:28 PM
To: [log in to unmask]
Subject: Re: 3% Hypertonic Saline in TBI

I had always thought that the debate around HS was settled, but there was a recent systemic review in the CMAJ 2016, that did not find it to be beneficial when compared to other mechanisms.

https://urldefense.proofpoint.com/v2/url?u=https-3A__www.cambridge.org_core_journals_canadian-2Djournal-2Dof-2Demergency-2Dmedicine_article_hypertonic-2Dsaline-2Din-2Dsevere-2Dtraumatic-2Dbrain-2Dinjury-2Da-2Dsystematic-2Dreview-2Dand-2Dmetaanalysis-2Dof-2Drandomized-2Dcontrolled-2Dtrials_C3FB8AA0FE865B173423F6933A293835&d=DwIFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=OEAcDBhKd1bBVBZ7Nc3Fw3kv26NKjEPV_b7vJcfJGSg&m=tvdOs2si0V99JWXRWv_62R3tco81J_M8W1ujd01U6RU&s=W3p2s8V1E2zLEkKnL9dRcfLj3Z_bPUE6daJbnaYeGQw&e=  <https://urldefense.proofpoint.com/v2/url?u=https-3A__www.cambridge.org_core_journals_canadian-2Djournal-2Dof-2Demergency-2Dmedicine_article_hypertonic-2Dsaline-2Din-2Dsevere-2Dtraumatic-2Dbrain-2Dinjury-2Da-2Dsystematic-2Dreview-2Dand-2Dmetaanalysis-2Dof-2Drandomized-2Dcontrolled-2Dtrials_C3FB8AA0FE865B173423F6933A293835&d=DwIFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=OEAcDBhKd1bBVBZ7Nc3Fw3kv26NKjEPV_b7vJcfJGSg&m=tvdOs2si0V99JWXRWv_62R3tco81J_M8W1ujd01U6RU&s=W3p2s8V1E2zLEkKnL9dRcfLj3Z_bPUE6daJbnaYeGQw&e= >

There is good discussion of this on SGEM:

https://urldefense.proofpoint.com/v2/url?u=http-3A__thesgem.com_2016_03_sgem150-2Dhypertonic-2Dsaline-2Dfor-2Dtraumatic-2Dbrain-2Dinjury_&d=DwIFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=OEAcDBhKd1bBVBZ7Nc3Fw3kv26NKjEPV_b7vJcfJGSg&m=tvdOs2si0V99JWXRWv_62R3tco81J_M8W1ujd01U6RU&s=dpV_RiETBQVYOH7AwimjWuQ2aCFkmM2IK4V-4eYgg08&e=  <https://urldefense.proofpoint.com/v2/url?u=http-3A__thesgem.com_2016_03_sgem150-2Dhypertonic-2Dsaline-2Dfor-2Dtraumatic-2Dbrain-2Dinjury_&d=DwIFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=OEAcDBhKd1bBVBZ7Nc3Fw3kv26NKjEPV_b7vJcfJGSg&m=tvdOs2si0V99JWXRWv_62R3tco81J_M8W1ujd01U6RU&s=dpV_RiETBQVYOH7AwimjWuQ2aCFkmM2IK4V-4eYgg08&e= >

I contrast these to the article below which actually did find HS was better.

https://urldefense.proofpoint.com/v2/url?u=https-3A__www.ncbi.nlm.nih.gov_pmc_articles_PMC4665128_&d=DwIFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=OEAcDBhKd1bBVBZ7Nc3Fw3kv26NKjEPV_b7vJcfJGSg&m=tvdOs2si0V99JWXRWv_62R3tco81J_M8W1ujd01U6RU&s=TBBDM38wa1HvJZp9TsYg-jiuCK2Y0bwB7w3mg6ymVUQ&e=  <https://urldefense.proofpoint.com/v2/url?u=https-3A__www.ncbi.nlm.nih.gov_pmc_articles_PMC4665128_&d=DwIFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=OEAcDBhKd1bBVBZ7Nc3Fw3kv26NKjEPV_b7vJcfJGSg&m=tvdOs2si0V99JWXRWv_62R3tco81J_M8W1ujd01U6RU&s=TBBDM38wa1HvJZp9TsYg-jiuCK2Y0bwB7w3mg6ymVUQ&e= >

That said…I go for it before I would use mannitol.  But it’s an interesting debate and am curious to hear what others are doing?
Mike Falk
NY, NY.

P.S.  I am adding Cochrane review of Mannitol.

https://urldefense.proofpoint.com/v2/url?u=http-3A__www.cochrane.org_CD001049_INJ-5Fmannitol-2Dfor-2Dacute-2Dtraumatic-2Dbrain-2Dinjury&d=DwIFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=OEAcDBhKd1bBVBZ7Nc3Fw3kv26NKjEPV_b7vJcfJGSg&m=tvdOs2si0V99JWXRWv_62R3tco81J_M8W1ujd01U6RU&s=qkZXGTa1P7tTdkDChQvAhsmK5Bkl9JihLpCrXLueU9I&e= 



> On Aug 1, 2017, at 3:57 PM, Tom Ruffin Jr <[log in to unmask]> wrote:
> 
> Recently the Neurosurgery department at our hospital has questioned the use of 3% hypertonic saline given in the ED for traumatic brain injury when clinically indicated. 
> 
> They site a lack of great data supporting improved mortality when given in the ED. 
> 
> To me there are not enough studies, looking at both mortality and morbidity, to not give it a shot in these critically injured kids. 
> 
> Despite the lack of great evidence I wanted to see what is being done around the country.
> 
> 1- Do you know of additional studies citing the use of 3% HTS in TBI. 
> 
> 2- Is anyone still using Mannitol?
> 
> 3- Do you have a protocol in place for when to use 3% HTS in TBI. 
> 
> 4- If a protocol is in place, who is involved?(Neurosurgery, critical 
> care, etc)
> 
> Thanks for your input!
> 
> Tom Ruffin
> For more information, send mail to [log in to unmask] with 
> the message: info PED-EM-L The URL for the PED-EM-L Web Page is:
>                 
> https://urldefense.proofpoint.com/v2/url?u=http-3A__listserv.brown.edu
> _ped-2Dem-2Dl.html&d=DwIFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=OEAcDBhKd1bBVBZ
> 7Nc3Fw3kv26NKjEPV_b7vJcfJGSg&m=tvdOs2si0V99JWXRWv_62R3tco81J_M8W1ujd01
> U6RU&s=keZkJndCVZn0_XLiIGP2ZQS9-J9NmUNOQlyYimhOobU&e=


For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:
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