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Higher Volume Hypertonic Saline and Increased Thrombotic Risk Without Improved Survival in Pediatric Traumatic Brain Injury

Webster, Danielle L, M.D.
http://rave.ohiolink.edu/etdc/view?acc_num=ucin1406810346

Abstract Details

2014, MS, University of Cincinnati, Medicine: Clinical and Translational Research.
Introduction and Objective: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality among children and adolescents in the United States. The most recent edition of the Guidelines for Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children and Adolescents endorse the use of hypertonic saline (HTS) for the treatment of severe pediatric TBI with effective doses between 6.5 and 10 ml/kg. This is a change from the previously recommended dose of 3-5ml/kg. To our knowledge, no studies have investigated the safety of this change in clinical practice. The primary objective of this study was to investigate the association between hypertonic saline administration, including associated serum sodium levels, and the outcome of deep venous thrombosis in pediatric patients following traumatic brain injury. A secondary objective of this study was to classify survival and neurologic outcomes among the study subjects. Methods: Single center retrospective cohort study of pediatric patients admitted to a large, tertiary, academic pediatric intensive care unit (PICU) between January 10, 2010 and June 30, 2013 with the diagnosis of traumatic brain injury and a Glasgow Coma Score (GCS) of less than or equal to eight. The primary outcome was development of deep venous thrombosis (DVT) of any vessel confirmed with ultrasonography. Results: Ninety-three patients with a median age of 5 years [Interquartile Range (IQR) 1.9, 13] were admitted between January 10, 2010 and June 30, 2013. There were 63 subjects admitted prior to May 31, 2012 (when the new guidelines were implemented at the institution) and 30 subjects admitted after May 31, 2012. An initial dose of >5ml/kg of HTS increased the probability of developing DVT but did not reach statistical significance [odds ratio, 1.3 (95% CI, 0.9-1.7), p = 0.1]. The cumulative total volume of HTS (ml/kg) given to each subject during the hospital stay was significantly associated with DVT [odds ratio, 1.6 (95% CI, 1.2-2.4), p = 0.01]. Peak sodium level and sustained sodium level (highest serum sodium level maintained for 72 consecutive hours) was also significantly associated with DVT [odds ratio per unit increase, 1.1 (95% CI, 1.0-1.1), p = 0.05]. A sustained sodium level of >= 160 mmol/L was highly associated with DVT (Fisher’s exact p = 0.02). After the guideline change implementation (May 2012), our institution saw an average increase in the cumulative total volume of HTS administered as well as an average increase of 7.9 mmol in sustained sodium levels (95% CI, 1.1-14.7, p = 0.02). The total volume of HTS given during the hospital stay was not associated with survival (p = 0.62). The odds of having a favorable Glasgow Outcome Scale (GOS) score of 4 or 5 was less for those subjects who maintained a sustained sodium >= 160 mmol/L [odds ratio, 0.1 (95% CI, 0.03-0.38), p= 0.008]. Conclusion: In children with severe TBI, the total volume of 3% HTS and sustained sodium levels >160 mmol/L are independently associated with the development of DVT without improvement in survival.
Erin Haynes, Dr.P.H. (Committee Chair)
Lin Fei, Ph.D. (Committee Member)
Jennifer M Kaplan, M.D. (Committee Member)
34 p.
Surgery
traumatic brain injury; TBI; pediatric; hypertonic saline; deep venous thrombosis; PICU

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Citations

  • Webster, M.D., D. L. (2014). Higher Volume Hypertonic Saline and Increased Thrombotic Risk Without Improved Survival in Pediatric Traumatic Brain Injury [Master's thesis, University of Cincinnati]. OhioLINK Electronic Theses and Dissertations Center. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1406810346

    APA Style (7th edition)

  • Webster, M.D., Danielle. Higher Volume Hypertonic Saline and Increased Thrombotic Risk Without Improved Survival in Pediatric Traumatic Brain Injury. 2014. University of Cincinnati, Master's thesis. OhioLINK Electronic Theses and Dissertations Center, http://rave.ohiolink.edu/etdc/view?acc_num=ucin1406810346.

    MLA Style (8th edition)

  • Webster, M.D., Danielle. "Higher Volume Hypertonic Saline and Increased Thrombotic Risk Without Improved Survival in Pediatric Traumatic Brain Injury." Master's thesis, University of Cincinnati, 2014. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1406810346

    Chicago Manual of Style (17th edition)

ucin1406810346
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This open access ETD is published by University of Cincinnati and OhioLINK.