X-Message-Number: 33220 Date: Wed, 12 Jan 2011 18:16:03 -0800 (PST) From: Subject: hypertonic saline for brain edema A number of CI's clinical reports make mention of tissue edema. FYI: In mainstream medicine, injections of hypertonic saline have replaced mannitol, due to its greater efficacy in treating edema. Although saline may not be the optimal stabilization solution, it is already available to funeral directors. BMC Neurosci. 2010 Dec 10;11:153. A comparative study on the efficacy of 10% hypertonic saline and equal volume of 20% mannitol in the treatment of experimentally induced cerebral edema in adult rats. Zeng HK, Wang QS, Deng YY, Jiang WQ, Fang M, Chen CB, Jiang X. Department of Emergency & Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, PR China. Abstract BACKGROUND: Hypertonic saline and mannitol are commonly used in the treatment of cerebral edema and elevated intracranial pressure (ICP) at present. In this connection, 10% hypertonic saline (HS) alleviates cerebral edema more effectively than the equal volume of 20% mannitol. However, the exact underlying mechanism for this remains obscure. This study aimed to explore the possible mechanism whereby 10% hypertonic saline can ameliorate cerebral edema more effectively than mannitol. RESULTS: Adult male Sprague-Dawley (SD) rats were subjected to permanent right-sided middle cerebral artery occlusion (MCAO) and treated with a continuous intravenous infusion of 10% HS, 20% mannitol or D-[1-3H(N)]-mannitol. Brain water content (BWC) as analyzed by wet-to-dry ratios in the ischemic hemisphere of SD rats decreased more significantly after 10% HS treatment compared with 20% mannitol. Concentration of serum Na+ and plasma crystal osmotic pressure of the 10% HS group at 2, 6, 12 and 18 h following permanent MCAO increased significantly when compared with 20% mannitol treated group. Moreover, there was negative correlation between the BWC of the ipsilateral ischemic hemisphere and concentration of serum Na+, plasma crystal osmotic pressure and difference value of concentration of serum Na+ and concentration of brain Na+ in ipsilateral ischemic hemisphere in the 10% HS group at the various time points after MCAO. A remarkable finding was the progressive accumulation of mannitol in the ischemic brain tissue. CONCLUSIONS: We conclude that 10% HS is more effective in alleviating cerebral edema than the equal volume of 20% mannitol. This is because 10% HS contributes to establish a higher osmotic gradient across BBB and, furthermore, the progressive accumulation of mannitol in the ischemic brain tissue counteracts its therapeutic efficacy on cerebral edema. PMID: 21143951 Free text> http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3004923/pdf/1471-2202-11-153.pdf J Neurosci Nurs. 2008 Dec;40(6):362-8. Challenging the gold standard: should mannitol remain our first-line defense against intracranial hypertension? Infanti JL. Hospital of the University of Pennsylvania, Philadelphia, USA. Abstract Mannitol has long been the "gold standard" for treatment of cerebral edema and refractory intracranial hypertension in traumatic brain injury, subarachnoid hemorrhage, and stroke. Studies performed in animals have shown that hypertonic saline (HS), in doses ranging from 3% to 10%, may be more effective than mannitol in treating these populations. Recently, randomized clinical trials have evaluated the efficacy and safety of HS versus mannitol in the treatment of elevated intracranial pressure (ICP). This research has been prompted by mounting concern about the side effects of mannitol, the limited ability to give multiple doses of the drug, and an increased understanding of cerebral physiology. Four studies have compared the use of HS and mannitol in brain-injured populations. These studies have shown that not only is HS a safe drug (no patients experienced adverse effects), it is also more efficient in reducing ICP. Efficiency is defined as the drug's ability to decrease ICP to acceptable levels and to maintain lower ICPs for a longer duration of time. It is important for nurses who administer osmotic diuretics to evaluate and understand the current research to provide educated and appropriate care. PMID: 19170304 Neurosurgery. 2005 Oct;57(4):727-36; discussion 727-36. Effects of 23.4% sodium chloride solution in reducing intracranial pressure in patients with traumatic brain injury: a preliminary study. Ware ML, Nemani VM, Meeker M, Lee C, Morabito DJ, Manley GT. Department of Neurological Surgery, University of California, San Francisco, California 94110, USA. Abstract OBJECTIVE: Mannitol is the standard of care for patients with increased intracranial pressure (ICP), but multiple administrations of mannitol risk renal toxicity and fluid accumulation in the brain parenchyma with consequent worsening of cerebral edema. This preliminary study assessed the safety and efficacy of small-volume injections of 23.4% sodium chloride solution for the treatment of intracranial hypertension in patients with traumatic brain injury who became tolerant to mannitol. METHODS: We retrospectively reviewed the charts of 13 adult patients with traumatic brain injury who received mannitol and 23.4% sodium chloride independently for the treatment of intracranial hypertension at San Francisco General Hospital between January and October 2003. Charts were reviewed to determine ICP, cerebral perfusion pressure, mean arterial pressure, serum sodium values, and serum osmolarity before and after treatment with 23.4% sodium chloride and mannitol. Complications were noted. RESULTS: The mean reductions in ICP after treatment were significant for both mannitol (P < 0.001) and hypertonic saline (P < 0.001); there were no significant differences between reductions in ICP when comparing the two agents (P = 0.174). The ICP reduction observed for hypertonic saline was durable, and its mean duration of effect (96 min) was significantly longer than that of mannitol treatment (59 min) (P = 0.016). No complications were associated with treatment with hypertonic saline. CONCLUSION: This study suggests that 23.4% hypertonic saline is a safe and effective treatment for elevated ICP in patients after traumatic brain injury. These results warrant a rigorous evaluation of its efficacy as compared to mannitol in a prospective randomized controlled trial. PMID: 16239885 Here rank order of effectiveness was beta-hydroxybutyrate > glycerine > saline. Jpn J Pharmacol. 2001 Oct;87(2):143-50. Effect of beta-hydroxybutyrate, a cerebral function improving agent, on cerebral hypoxia, anoxia and ischemia in mice and rats. Suzuki M, Suzuki M, Sato K, Dohi S, Sato T, Matsuura A, Hiraide A. Shimizu Research Center, Research and Development Division, Shimizu Pharmaceutical Co., Ltd., Shizuoka, Japan. Abstract Although improving energy metabolism in ischemic brain has been accepted for the treatment of cerebrovascular diseases, administration of glucose, as an energy substrate, would aggravate ischemic brain damage via activating anaerobic glycolysis, which leads to lactate accumulation. Beta-hydroxybutyrate (BHB) is one of the ketone bodies that can be utilized as an energy source during starvation. The purpose of our study was to define the protective effects of BHB on brain damage induced by hypoxia, anoxia and ischemia. The isotonic solution of BHB administered 30 min before the induction of ischemia at doses over 50 mg x kg(-1) x h(-1) showed remarkable protective effects against hypoxia and anoxia. BHB administered immediately after a bilateral carotid artery ligation at a dose of 30 mg x kg(-1) x h(-1) significantly suppressed the elevation of cerebral water and sodium contents as well as maintaining high ATP and low lactate levels. In contrast, glycerin, a hypertonic agent, substantially reduced the water content but did not show any significant effect on other parameters. We demonstrated that BHB, unlike glycerin, when used as an energy substrate in ischemic brain, has protective effects on cerebral hypoxia, anoxia and ischemia-induced metabolic change. PMID: 11700013 Free text> http://www.jstage.jst.go.jp/article/jjp/87/2/143/_pdf Rate This Message: http://www.cryonet.org/cgi-bin/rate.cgi?msg=33220