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Sodium lactate versus mannitol in the treatment of intracranial hypertensive episodes in severe traumatic brain-injured patients

Intensive Care Medicine volume 35, pages 471–479 (2009)Cite this article

Abstract

Objectives

Traumatic brain injury (TBI) is still a major cause of mortality and morbidity. Recent trials have failed to demonstrate a beneficial outcome from therapeutic treatments such as corticosteroids, hypothermia and hypertonic saline. We investigated the effect of a new hyperosmolar solution based on sodium lactate in controlling raised intracranial pressure (ICP).

Design and setting

Prospective open randomized study in an adult ICU.

Patients

Thirty-four patients with isolated severe TBI (Glasgow Coma Scale ≤ 8) and intracranial hypertension were allocated to receive equally hyperosmolar and isovolumic therapy, consisting of either mannitol or sodium lactate. Rescue therapy by crossover to the alternative treatment was indicated when ICP could not be controlled. The primary endpoint was efficacy in lowering ICP after 4 h, with a secondary endpoint of the percentage of successfully treated episodes of intracranial hypertension. The analysis was performed with both intention-to-treat and actual treatments provided.

Measurements and results

Compared to mannitol, the effect of the lactate solution on ICP was significantly more pronounced (7 vs. 4 mmHg, P = 0.016), more prolonged (fourth-hour-ICP decrease: −5.9 ± 1 vs. −3.2 ± 0.9 mmHg, P = 0.009) and more frequently successful (90.4 vs. 70.4%, P = 0.053).

Conclusion

Acute infusion of a sodium lactate-based hyperosmolar solution is effective in treating intracranial hypertension following traumatic brain injury. This effect is significantly more pronounced than that of an equivalent osmotic load of mannitol. Additionally, in this specific group of patients, long-term outcome was better in terms of GOS in those receiving as compared to mannitol. Larger trials are warranted to confirm our findings.

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Acknowledgments

The study has been sponsored by Innogene Kalbiotech Pte. Ltd. 24 Raffles Place 27-06 Clifford Center, Singapore, 04862. The authors are most grateful to Dr. Rikrik Ilyas for a constant support, to Professor Nino Stocchetti for helpful comments and suggestions, to Professor Mervyn Singer for stimulating discussions and careful review of the manuscript and to Mr. Gareth Butt for the English corrections to this paper.

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Authors and Affiliations

  1. Service de Réanimation, Faculté de Médecine and CHU de Nice, Hôpital Saint-Roch, 5 Rue Pierre Dévoluy, 06006, Nice Cedex 1, France

    Carole Ichai, Guy Armando, Jean-Christophe Orban, Laurent Rami, Corine Samat-Long & Dominique Grimaud

  2. Département d’Informatique Médicale, CHU de Nice, Hôpital Cimiez, Avenue Reine Victoria, 06000, Nice, France

    Frederic Berthier

  3. Inserm U884 and Université Joseph Fourier, 38041, Grenoble Cedex, France

    Xavier Leverve

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  1. Carole Ichai
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Correspondence to Carole Ichai.

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Ichai, C., Armando, G., Orban, JC. et al. Sodium lactate versus mannitol in the treatment of intracranial hypertensive episodes in severe traumatic brain-injured patients. Intensive Care Med 35, 471–479 (2009). https://doi.org/10.1007/s00134-008-1283-5

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  • DOI: https://doi.org/10.1007/s00134-008-1283-5

Keywords

  • TBI
  • Osmotherapy
  • Cerebral edema
  • Plasma ions
  • Neurological outcome
  • Disability