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I applaud Jim's thought process.

And there is not an absence of evidence but rather there is just not a
surfeit of evidence. My understanding though is that there is even less
reliable evidence for mannitol. Rather "it is what we use".

Rick
Fairfax

Since we are trading anecdotes, I remember a patient I had a few months
back on the dark (adult) side. Had a bleed and was deteriorating. Planned
on intubating as he drifted close to the proper GCS -- they are expected to
deteriorate.

Critical Care attending says hold on, comes down, pushes a couple amps of
sodium bicarb and the guy completely wakes up and asks if he can go to the
bathroom.

On Wed, Aug 2, 2017 at 8:55 AM, Chamberlain, James <
[log in to unmask]> wrote:

> 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:
>                  https://urldefense.proofpoint.com/v2/url?u=http-3A__
> listserv.brown.edu_ped-2Dem-2Dl.html&d=DwIFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=
> OEAcDBhKd1bBVBZ7Nc3Fw3kv26NKjEPV_b7vJcfJGSg&m=
> tvdOs2si0V99JWXRWv_62R3tco81J_M8W1ujd01U6RU&s=keZkJndCVZn0_XLiIGP2ZQS9-
> J9NmUNOQlyYimhOobU&e=
>
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