Clinical Outcomes of Hypertonic Saline vs Mannitol Treatment Among Children With Traumatic Brain Injury
Authors: Shu-Ling Chong, Yanan Zhu, Quan Wang, Paula Caporal, Juan D. Roa, Freddy Israel Pantoja Chamorro, Thelma Elvira Teran Miranda, Hongxing Dang, Chin Seng Gan, Qalab Abbas, Ivan J. Ardila, Mohannad Ahmad Antar, Jesús A. Domínguez-Rojas, María Miñambres Rodríguez, Natalia Zita Watzlawik, Natalia Elizabeth Gómez Arriola, Adriana Yock-Corrales, Rubén Eduardo Lasso-Palomino, Ming Mei Xiu, Jacqueline S. M. Ong, Hiroshi Kurosawa, Gabriela Aparicio, Chunfeng Liu, Rujipat Samransamruajkit, Juan C. Jaramillo-Bustamante, Nattachai Anantasit, Yek Kee Chor, Deborah M. Turina, Pei Chuen Lee, Marisol Fonseca Flores, Francisco Javier Pilar Orive, Jane Ng Pei Wen, Sebastián González-Dambrauskas, Jan Hau Lee, Yasser M. Kazzaz, Ji Jian, Suyun Qian, Lijia Fan, Olive Pei Ee Lee, Soo Lin Chuah, Kai You, Tao Zhang, Deiby Lasso Noguera, Esteban Cerón, Andrea Leal Barceló, Susana Beatriz Reyes Domínguez, Cesia J Ortega Ocas
Journal: JAMA Network Open (2025)

Importance The use of hypertonic saline (HTS) vs mannitol in the control of elevated intracranial pressure (ICP) secondary to neurotrauma is debated. Objective To compare mortality and functional outcomes of treatment with 3% HTS vs 20% mannitol among children with moderate to severe traumatic brain injury (TBI) at risk of elevated ICP. Design, Setting, and Participants This prospective, multicenter cohort study was conducted between June 1, 2018, and December 31, 2022, at 28 participating pediatric intensive care units in the Pediatric Acute and Critical Care Medicine in Asia Network (PACCMAN) and the Red Colaborativa Pediátrica de Latinoamérica (LARed) in Asia, Latin America, and Europe. The study included children (aged &amp;amp;lt;18 years) with moderate to severe TBI (Glasgow Coma Scale [GCS] score ≤13). Exposure Treatment with 3% HTS compared with 20% mannitol. Main Outcomes and Measures Multiple log-binomial regression analysis was performed for mortality, and multiple linear regression analysis was performed for discharge Pediatric Cerebral Performance Category (PCPC) scores and 3-month Glasgow Outcome Scale–Extended Pediatric Version (GOS-E-Peds) scores. Inverse probability of treatment weighting was also performed using the propensity score method to control for baseline imbalance between groups. Results This study included 445 children with a median age of 5.0 (IQR, 2.0-11.0) years. More than half of the patients (279 [62.7%]) were boys, and 344 (77.3%) had severe TBI. Overall, 184 children (41.3%) received 3% HTS, 82 (18.4%) received 20% mannitol, 69 (15.5%) received both agents, and 110 (24.7%) received neither agent. The mortality rate was 7.1% (13 of 184 patients) in the HTS group and 11.0% (9 of 82 patients) in the mannitol group ( P = .34). After adjusting for age, sex, presence of child abuse, time between injury and hospital arrival, lowest GCS score in the first 24 hours, and presence of extradural hemorrhage, no between-group differences in mortality, hospital discharge PCPC scores, or 3-month GOS-E-Peds scores were observed. Conclusions and Relevance In this cohort study of children with moderate to severe TBI, the use of HTS was not associated with increased survival or improved functional outcomes compared with mannitol. Future large multicenter randomized clinical trials are required to validate these findings.