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1.
Am J Gastroenterol ; 115(11): 1775-1785, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33156095

RESUMO

Hyponatremia is frequently seen in patients with ascites secondary to advanced cirrhosis and portal hypertension. Although not apparent in the early stages of cirrhosis, the progression of cirrhosis and portal hypertension leads to splanchnic vasodilation, and this leads to the activation of compensatory mechanisms such as renin-angiotensin-aldosterone system (RAAS), sympathetic nervous system, and antidiuretic hormone (ADH) to ameliorate low circulatory volume. The net effect is the avid retention of sodium and water to compensate for the low effective circulatory volume, resulting in the development of ascites. These compensatory mechanisms lead to impairment of the kidneys to eliminate solute-free water in decompensated cirrhosis. Nonosmotic secretion of antidiuretic hormone (ADH), also known as arginine vasopressin, further worsens excess water retention and thereby hyponatremia. The management of hyponatremia in this setting is a challenge as conventional therapies for hyponatremia including fluid restriction and correction of hypokalemia are frequently inefficacious. In this review, we discuss the pathophysiology, complications, and various treatment modalities, including albumin infusion, selective vasopressin receptor antagonists, or hypertonic saline for patients with severe hyponatremia and those awaiting liver transplantation.


Assuntos
Ascite/metabolismo , Hipertensão Portal/metabolismo , Hiponatremia/metabolismo , Cirrose Hepática/metabolismo , Sistema Renina-Angiotensina/fisiologia , Vasopressinas/metabolismo , Lesão Renal Aguda/metabolismo , Lesão Renal Aguda/fisiopatologia , Insuficiência Hepática Crônica Agudizada/metabolismo , Insuficiência Hepática Crônica Agudizada/fisiopatologia , Albuminas/uso terapêutico , Antagonistas dos Receptores de Hormônios Antidiuréticos/uso terapêutico , Ascite/fisiopatologia , Hidratação , Encefalopatia Hepática/metabolismo , Encefalopatia Hepática/fisiopatologia , Síndrome Hepatorrenal/metabolismo , Síndrome Hepatorrenal/fisiopatologia , Humanos , Hipertensão Portal/fisiopatologia , Hiponatremia/fisiopatologia , Hiponatremia/terapia , Cirrose Hepática/fisiopatologia , Transplante de Fígado , Solução Salina Hipertônica/uso terapêutico , Circulação Esplâncnica/fisiologia , Tolvaptan/uso terapêutico , Vasodilatação/fisiologia
2.
Medicine (Baltimore) ; 99(35): e21655, 2020 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-32871879

RESUMO

BACKGROUND: To compare the effects of 3% hypertonic saline solution and 20% mannitol solution on intracranial hypertension. METHODS: WAN-FANGDATA, CNKI, and CQVIP databases were searched, and relevant literatures of randomized controlled trials comparing 3% hypertonic saline solution with mannitol in reducing intracranial hypertension from 2010 to October 2019 were collected. Meta-analysis was performed using RevMan software. RESULTS: As a result, 10 articles that met the inclusion criteria were finally included. A total of 544 patients were enrolled in the study, 270 in the hypertonic saline group and 274 in the mannitol group. There was no significant difference in the decrease of intracranial pressure and the onset time of drug between the 2 groups after intervention (all P > .05). There was a statistically significant difference between the hypertonic saline group and the mannitol group in terms of duration of effect in reducing intracranial pressure (95% confidence interval: 0.64-1.05, Z = 8.09, P < .00001) and cerebral perfusion pressure after intervention (95% confidence interval: 0.15-0.92, Z = 2.72, P = .007). CONCLUSION: Both 3% hypertonic saline and mannitol can effectively reduce intracranial pressure, but 3% hypertonic saline has a more sustained effect on intracranial pressure and can effectively increase cerebral perfusion pressure.


Assuntos
Lesões Encefálicas Traumáticas/tratamento farmacológico , Diuréticos Osmóticos/uso terapêutico , Hipertensão Intracraniana/tratamento farmacológico , Manitol/uso terapêutico , Solução Salina Hipertônica/uso terapêutico , Lesões Encefálicas Traumáticas/complicações , Diuréticos Osmóticos/farmacologia , Humanos , Hipertensão Intracraniana/etiologia , Pressão Intracraniana/efeitos dos fármacos , Manitol/farmacologia , Solução Salina Hipertônica/farmacologia
3.
Medicine (Baltimore) ; 99(38): e22004, 2020 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-32957318

RESUMO

BACKGROUND: Mannitol and hypertonic saline (HTS) are effective in reducing intracranial pressure (ICP) after severe traumatic brain injury (TBI). However, their efficacy on the ICP has not been evaluated rigorously. OBJECTIVE: To evaluate the efficacy of repeated bolus dosing of HTS and mannitol in similar osmotic burdens to treat intracranial hypertension (ICH) in patients with severe TBI. METHODS: The authors used an alternating treatment protocol to evaluate the efficacy of HTS with that of mannitol given for ICH episodes in patients treated for severe TBI at their hospital during 2017 to 2019. Doses of similar osmotic burdens (20% mannitol, 2 ml/kg, or 10% HTS, 0.63 ml/kg, administered as a bolus via a central venous catheter, infused over 15 minutes) were given alternately to the individual patient with severe TBI during ICH episodes. The choice of osmotic agents for the treatment of the initial ICH episode was determined on a randomized basis; osmotic agents were alternated for every subsequent ICH episode in each individual patient. intracranial pressure (ICP), mean arterial pressure (MAP), and cerebral perfusion pressure (CPP) were continuously monitored between the beginning of each osmotherapy and the return of ICP to 20 mm Hg. The duration of the effect of ICP reduction (between the beginning of osmotherapy and the return of ICP to 20 mm Hg), the maximum reduction of ICP and its time was recorded after each dose. Serum sodium and plasma osmolality were measured before, 0.5 hours and 3 hours after each dose. Adverse effects such as central pontine myelinolysis (CPM), severe fluctuations of serum sodium and plasma osmolality were assessed to evaluate the safety of repeated dosing of HTS and mannitol. RESULTS: Eighty three patients with severe TBI were assessed, including 437 ICH episodes, receiving 236 doses of HTS and 221 doses of mannitol totally. There was no significant difference between equimolar HTS and mannitol boluses on the magnitude of ICP reduction, the duration of effect, and the time to lowest ICP achieved (P > .05). The proportion of efficacious boluses was higher for HTS than for mannitol (P = .016), as was the increase in serum sodium (P = .038). The serum osmolality increased immediately after osmotherapy with a significant difference (P = .017). No cases of CPM were detected. CONCLUSION: Repeat bolus dosing of 10% HTS and 20% mannitol appears to be significantly and similarly effective for treating ICH in patients with severe TBI. The proportion of efficacious doses of HTS on ICP reduction may be higher than mannitol.


Assuntos
Lesões Encefálicas Traumáticas/complicações , Diuréticos Osmóticos/uso terapêutico , Hipertensão Intracraniana/tratamento farmacológico , Hipertensão Intracraniana/etiologia , Manitol/uso terapêutico , Solução Salina Hipertônica/uso terapêutico , Adulto , Circulação Cerebrovascular/efeitos dos fármacos , Diuréticos Osmóticos/administração & dosagem , Diuréticos Osmóticos/efeitos adversos , Feminino , Humanos , Pressão Intracraniana/efeitos dos fármacos , Masculino , Manitol/administração & dosagem , Manitol/efeitos adversos , Pessoa de Meia-Idade , Solução Salina Hipertônica/administração & dosagem , Solução Salina Hipertônica/efeitos adversos , Índices de Gravidade do Trauma
4.
Mayo Clin Proc ; 95(8): 1660-1670, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32605782

RESUMO

OBJECTIVE: To compare elastic bandage (EB) vs hypertonic albumin solution administration to increase fluid removal by enhancing loop diuretic efficiency (DE) in patients with volume overload and diuretic resistance. PATIENTS AND METHODS: In this historic cohort study with propensity matching, we included diuretic-resistant adult (≥18 years) patients with volume overload after fluid resuscitation admitted in the intensive care unit from January 1, 2006, through June 30, 2017. Regression models and propensity matching were used to assess the associations of these interventions with changes in DE and other clinical outcomes. RESULTS: Of 1147 patients (median age, 66; interquartile range [IQR], 56-76 years; 51% [n=590] men), 384 (33%) received EB and 763 (67%) received hypertonic albumin solution. In adjusted models, EB was significantly associated with higher DE compared with hypertonic albumin solution (odds ratio, 1.37; 95% CI, 1.04 to 1.81; P=.004). After propensity matching of 345 pairs, DE remained significantly different between the 2 groups (median, 2111; IQR, 1092 to 4665 mL for EB vs median, 1829; IQR, 1032 to 3436 mL for hypertonic albumin solution; P=.02). EB, male sex, lower baseline serum urea nitrogen level, lower Charlson Comorbidity Index score, and higher baseline left ventricular ejection fraction were DE determinants. The lowest DE quartile (<1073 mL/40-mg furosemide equivalent) following adjustment for known predictors of mortality remained independently associated with higher 90-day death rate (odds ratio, 1.64; 95% CI, 1.13 to 2.36; P=.009). CONCLUSION: EB use is associated with greater DE than hypertonic albumin solution during the deescalation phase of sepsis resuscitation. Prospective clinical trials would validate the findings of this hypothesis-generating study.


Assuntos
Albuminas/uso terapêutico , Bandagens Compressivas/estatística & dados numéricos , Diuréticos/uso terapêutico , Unidades de Terapia Intensiva/estatística & dados numéricos , Solução Salina Hipertônica/uso terapêutico , Desequilíbrio Hidroeletrolítico/terapia , Idoso , Feminino , Hidratação/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Resultado do Tratamento
5.
Artigo em Inglês | MEDLINE | ID: mdl-32630399

RESUMO

Treatment with osmoactive agents such as mannitol or hypertonic saline (HTS) solutions is widely used to manage or prevent the increase of intracranial pressure (ICP) in central nervous system (CNS) disorders. We sought to evaluate the variability and mean plasma concentrations of the water and electrolyte balance parameters in critically ill patients treated with osmotic therapy and their influence on mortality. This cohort study covered patients hospitalized in an intensive care unit (ICU) from January 2017 to June 2019 with presumed increased ICP or considered to be at risk of it, treated with 15% mannitol (G1, n = 27), a combination of 15% mannitol and 10% hypertonic saline (HTS) (G2, n = 33) or 10% HTS only (G3, n = 13). Coefficients of variation (Cv) and arithmetic means (mean) were calculated for the parameters reflecting the water and electrolyte balance, i.e., sodium (NaCv/NaMean), chloride (ClCv/ClMean) and osmolality (mOsmCv/mOsmMean). In-hospital mortality was also analyzed. The study group comprised 73 individuals (36 men, 49%). Mortality was 67% (n = 49). Median NaCv (G1: p = 0.002, G3: p = 0.03), ClCv (G1: p = 0.02, G3: p = 0.04) and mOsmCv (G1: p = 0.001, G3: p = 0.02) were higher in deceased patients. NaMean (p = 0.004), ClMean (p = 0.04), mOsmMean (p = 0.003) were higher in deceased patients in G3. In G1: NaCv (AUC = 0.929, p < 0.0001), ClCv (AUC = 0.817, p = 0.0005), mOsmCv (AUC = 0.937, p < 0.0001) and in G3: NaMean (AUC = 0.976, p < 0.001), mOsmCv (AUC = 0.881, p = 0.002), mOsmMean (AUC = 1.00, p < 0.001) were the best predictors of mortality. The overall mortality prediction for combined G1+G2+G3 was very good, with AUC = 0.886 (p = 0.0002). The mortality of critically ill patients treated with osmotic agents is high. Electrolyte disequilibrium is the independent predictor of mortality regardless of the treatment method used. Variations of plasma sodium, chloride and osmolality are the most deleterious factors regardless of the absolute values of these parameters.


Assuntos
Lesões Encefálicas , Hipertensão Intracraniana , Pressão Intracraniana/efeitos dos fármacos , Solução Salina Hipertônica/uso terapêutico , Estudos de Coortes , Feminino , Humanos , Hipertensão Intracraniana/tratamento farmacológico , Hipertensão Intracraniana/mortalidade , Masculino , Equilíbrio Hidroeletrolítico
6.
Z Gerontol Geriatr ; 53(5): 463-472, 2020 Aug.
Artigo em Alemão | MEDLINE | ID: mdl-32691149

RESUMO

The aim of this continuing medical education (CME) article (part II) is to describe the particular challenge of the treatment of hyponatremia, which occurs in older patients. This part II follows on from part I concerning the diagnosis in the previous volume. A staged approach is necessary. The best treatment is always when the underlying cause can be eliminated. Hyponatremia in older patients is mainly induced by the syndrome of inappropriate antidiuretic hormone (SIADH) secretion. The authors use a concept for the first, second and third line strategy: (1) changing or discontinuation of drugs, (2) fluid restriction and (3) tolvaptan medication. The algorithm for treatment should be simple. It also contains recommendations for the correction rate. Caution is also needed in order to avoid the occurrence of an osmotic demyelination syndrome (ODS).


Assuntos
Antagonistas dos Receptores de Hormônios Antidiuréticos/uso terapêutico , Hidratação/métodos , Hiponatremia/terapia , Síndrome de Secreção Inadequada de HAD/complicações , Solução Salina Hipertônica/uso terapêutico , Tolvaptan/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Terapia Combinada , Humanos , Hiponatremia/diagnóstico , Hiponatremia/etiologia , Síndrome de Secreção Inadequada de HAD/diagnóstico , Infusões Intravenosas , Resultado do Tratamento
9.
Cochrane Database Syst Rev ; 2: CD008816, 2020 02 28.
Artigo em Inglês | MEDLINE | ID: mdl-32107770

RESUMO

BACKGROUND: Inhalation of hypertonic saline improves sputum rheology, accelerates mucociliary clearance and improves clinical outcomes of people with cystic fibrosis. This is an update of a previously published Cochrane Review. OBJECTIVES: To determine whether the timing of hypertonic saline inhalation (in relation to airway clearance techniques or in relation to time of day) has an impact on its clinical efficacy in people with cystic fibrosis. SEARCH METHODS: We identified relevant randomised and quasi-randomised controlled trials from the Cochrane Cystic Fibrosis Trials Register, the Physiotherapy Evidence Database (PEDro), and international cystic fibrosis conference proceedings. Date of the last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register: 28 February 2019. SELECTION CRITERIA: Any trial of hypertonic saline in people with cystic fibrosis where timing of inhalation was the randomised element in the study protocol with either: inhalation up to six hours before airway clearance techniques compared to inhalation during airway clearance techniques compared to inhalation up to six hours after airway clearance techniques; or morning compared to evening inhalation with any definition provided by the author. DATA COLLECTION AND ANALYSIS: Both authors independently assessed the trials identified by the search for potential inclusion in the review. The certainty of the evidence was assessed using GRADE. MAIN RESULTS: The searches identified 104 trial reports which represented 51 trials, of which three cross-over trials (providing data on 77 participants) met our inclusion criteria. We present three comparisons: inhalation before versus during airway clearance techniques; inhalation before versus after airway clearance techniques; and inhalation during versus after airway clearance techniques. One trial (50 participants), given its three-arm design, was eligible for all three comparisons. No trials compared morning versus evening inhalation of hypertonic saline. The evidence from the three trials was judged to be of low quality downgraded for limitations (high risk of bias due to blinding) and indirectness (all participants are adults, and therefore not applicable to children). Intervention periods ranged from one treatment to three treatments in one day. There were no clinically important differences between the timing regimens of inhaling hypertonic saline before, during or after airway clearance techniques in the mean amount of improvement in lung function or symptom scores (77 participants), with the between-group comparisons being non-significant (low-certainty evidence). While there may be little or no difference in the rating of satisfaction when hypertonic saline was inhaled before versus during the airway clearance techniques (64 participants) (with the 95% confidence interval including the possibility of both a higher and lower rating of satisfaction), satisfaction may be lower on a 100-mm scale when inhaled after the airway clearance techniques compared to before: mean difference (MD) 20.38 mm (95% confidence interval (CI) 12.10 to 28.66) and when compared to during the techniques, MD 14.80 mm (95% CI 5.70 to 23.90). Perceived effectiveness showed similar results: little or no difference for inhalation before versus during airway clearance techniques (64 participants); may be lower when inhaled after the airway clearance techniques compared to before, MD 10.62 (95% CI 2.54 to 18.70); and also when compared to during the techniques, MD 15.60 (95% CI 7.55 to 23.65). There were no quality of life or adverse events reported in any of the trials. AUTHORS' CONCLUSIONS: Timing of hypertonic saline inhalation makes little or no difference to lung function (low-certainty evidence). However, inhaling hypertonic saline before or during airway clearance techniques may maximise perceived efficacy and satisfaction. The long-term efficacy of hypertonic saline has only been established for twice-daily inhalations; however, if only one dose per day is tolerated, the time of day at which it is inhaled could be based on convenience or tolerability until evidence comparing these regimens is available. The identified trials were all of very short intervention periods, so longer-term research could be conducted to establish the effects arising from regular use, which would incorporate the influence of changes in adherence with long-term use, as well as generating data on any adverse effects that occur with long-term use.


Assuntos
Fibrose Cística/tratamento farmacológico , Depuração Mucociliar , Solução Salina Hipertônica/uso terapêutico , Administração por Inalação , Esquema de Medicação , Humanos , Solução Salina Hipertônica/administração & dosagem , Escarro/metabolismo
11.
Cochrane Database Syst Rev ; 1: CD010904, 2020 01 17.
Artigo em Inglês | MEDLINE | ID: mdl-31978260

RESUMO

BACKGROUND: Increased intracranial pressure has been shown to be strongly associated with poor neurological outcomes and mortality for patients with acute traumatic brain injury. Currently, most efforts to treat these injuries focus on controlling the intracranial pressure. Hypertonic saline is a hyperosmolar therapy that is used in traumatic brain injury to reduce intracranial pressure. The effectiveness of hypertonic saline compared with other intracranial pressure-lowering agents in the management of acute traumatic brain injury is still debated, both in the short and the long term. OBJECTIVES: To assess the comparative efficacy and safety of hypertonic saline versus other intracranial pressure-lowering agents in the management of acute traumatic brain injury. SEARCH METHODS: We searched Cochrane Injuries' Specialised Register, CENTRAL, PubMed, Embase Classic+Embase, ISI Web of Science: Science Citation Index and Conference Proceedings Citation Index-Science, as well as trials registers, on 11 December 2019. We supplemented these searches with searches of four major Chinese databases on 19 September 2018. We also checked bibliographies, and contacted trial authors to identify additional trials. SELECTION CRITERIA: We sought to identify all randomised controlled trials (RCTs) of hypertonic saline versus other intracranial pressure-lowering agents for people with acute traumatic brain injury of any severity. We excluded cross-over trials as incompatible with assessing long-term outcomes. DATA COLLECTION AND ANALYSIS: Two review authors independently screened search results to identify potentially eligible trials and extracted data using a standard data extraction form. Outcome measures included: mortality at end of follow-up (all-cause); death or disability (as measured by the Glasgow Outcome Scale (GOS)); uncontrolled intracranial pressure (defined as failure to decrease the intracranial pressure to target and/or requiring additional intervention); and adverse events e.g. rebound phenomena; pulmonary oedema; acute renal failure during treatment). MAIN RESULTS: Six trials, involving data from 287 people, met the inclusion criteria. The majority of participants (91%) had a diagnosis of severe traumatic brain injury. We had concerns about particular domains of risk of bias in each trial, as physicians were not reliably blinded to allocation, two trials contained participants with conditions other than traumatic brain injury and in one trial, we had concerns about missing data for important outcomes. The original protocol was available for only one trial and other trials (where registered) were registered retrospectively. Meta-analysis for both the primary outcome (mortality at final follow-up) and for 'poor outcome' as per conventionally dichotomised GOS criteria, was only possible for two trials. Synthesis of long-term outcomes was inhibited by the fact that two trials ceased data collection within two hours of a single bolus dose of an intracranial pressure-lowering agent and one at discharge from the intensive care unit (ICU). Only three trials collected data after participants were released from hospital, one of which did not report mortality and reported a 'poor outcome' by GOS criteria in an unconventional way. Substantial missing data in a key trial meant that in meta-analysis we report 'best-case' and 'worst-case' estimates alongside available case analysis. In no scenario did we discern a clear difference between treatments for either mortality or poor neurological outcome. Due to variation in modes of drug administration (including whether it followed or did not follow cerebrospinal fluid (CSF) drainage, as well as different follow-up times and ways of reporting changes in intracranial pressure, as well as no uniform definition of 'uncontrolled intracranial pressure', we did not perform meta-analysis for this outcome and report results narratively, by individual trial. Trials tended to report both treatments to be effective in reducing elevated intracranial pressure but that hypertonic saline had increased benefits, usually adding that pretreatment factors need to be considered (e.g. serum sodium and both system and brain haemodynamics). No trial provided data for our other outcomes of interest. We consider evidence quality for all outcomes to be very low, as assessed by GRADE; we downgraded all conclusions due to imprecision (small sample size), indirectness (due to choice of measurement and/or selection of participants without traumatic brain injury), and in some cases, risk of bias and inconsistency. Only one of the included trials reported data on adverse effects; a rebound phenomenon, which was present only in the comparator group (mannitol). None of the trials reported data on pulmonary oedema or acute renal failure during treatment. On the whole, trial authors do not seem to have rigorously sought to collect data on adverse events. AUTHORS' CONCLUSIONS: This review set out to find trials comparing hypertonic saline to a potential range of other intracranial pressure-lowering agents, but only identified trials comparing it with mannitol or mannitol in combination with glycerol. Based on limited data, there is weak evidence to suggest that hypertonic saline is no better than mannitol in efficacy and safety in the long-term management of acute traumatic brain injury. Future research should be comprised of large, multi-site trials, prospectively registered, reported in accordance with current best practice. Trials should investigate issues such as the type of traumatic brain injury suffered by participants and concentration of infusion and length of time over which the infusion is given.


Assuntos
Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas/complicações , Hipertensão Intracraniana/tratamento farmacológico , Pressão Intracraniana/efeitos dos fármacos , Solução Salina Hipertônica/uso terapêutico , Escala de Resultado de Glasgow , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto
12.
Clin J Sport Med ; 30(1): 8-13, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31855907

RESUMO

OBJECTIVES: To determine whether oral administration of 3% hypertonic saline (HTS) is as efficacious as intravenous (IV) 3% saline in reversing symptoms of mild-to-moderate symptomatic exercise-associated hyponatremia (EAH) in athletes during and after a long-distance triathlon. DESIGN: Noninferiority, open-label, parallel-group, randomized control trial to IV or oral HTS. We used permuted block randomization with sealed envelopes, containing the word either "oral" or "IV." SETTING: Annual long-distance triathlon (3.8-km swim, 180-km bike, and 42-km run) at Mont-Tremblant, Quebec, Canada. PARTICIPANTS: Twenty race finishers with mild to moderately symptomatic EAH. INDEPENDENT VARIABLES: Age, sex, race finish time, and 9 clinical symptoms. MAIN OUTCOME MEASURES: Time from treatment to discharge. METHODS: We successfully randomized 20 participants to receive either an oral (n = 11) or IV (n = 9) bolus of HTS. We performed venipuncture to measure serum sodium (Na) at presentation to the medical clinic and at time of symptom resolution after the intervention. RESULTS: The average time from treatment to discharge was 75.8 minutes (SD 29.7) for the IV treatment group and 50.3 minutes (SD 26.8) for the oral treatment group (t test, P = 0.02). Serum Na before and after treatment was not significantly different in both groups. There was no difference on presentation between groups in age, sex, or race finish time, both groups presented with an average of 6 symptoms. CONCLUSIONS: Oral HTS is effective in reversing symptoms of mild-to-moderate hyponatremia in EAH.


Assuntos
Exercício Físico/fisiologia , Hiponatremia/tratamento farmacológico , Resistência Física/fisiologia , Solução Salina Hipertônica/uso terapêutico , Administração Oral , Adulto , Estudos de Equivalência como Asunto , Feminino , Humanos , Hiponatremia/diagnóstico , Hiponatremia/etiologia , Masculino , Pessoa de Meia-Idade , Sódio/sangue , Fatores de Tempo , Resultado do Tratamento
13.
Pediatr Emerg Care ; 36(4): e239-e241, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31804428

RESUMO

The "Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines" published in Pediatric Critical Care Medicine in 2019 provides new and updated recommendations applicable to the emergency department management of children with severe traumatic brain injury. Practice-changing takeaways include specific recommendations for administration of 3% hypertonic saline, administration of seizure prophylaxis, and avoiding hyperventilation.


Assuntos
Lesões Encefálicas Traumáticas/terapia , Serviço Hospitalar de Emergência/normas , Pediatria/normas , Guias de Prática Clínica como Assunto , Criança , Escala de Coma de Glasgow , Implementação de Plano de Saúde , Humanos , Solução Salina Hipertônica/uso terapêutico
14.
J Am Coll Surg ; 230(3): 322-330.e2, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31843691

RESUMO

BACKGROUND: Hypertonic saline (23.4%, HTS) bolus administration is common practice for refractory intracranial hypertension, but its effects on coagulation are unknown. We hypothesize that 23.4% HTS in whole blood results in progressive impairment of coagulation in vitro and in vivo in a murine model of traumatic brain injury (TBI). STUDY DESIGN: For the in vitro study, whole blood was collected from 10 healthy volunteers, and citrated native thrombelastography was performed with normal saline (0.9%, NS) and 23.4% HTS in serial dilutions (2.5%, 5%, and 10%). For the in vivo experiment, we assessed the effects of 23.4% HTS bolus vs NS on serial thrombelastography and tail-bleeding times in a TBI murine model (n = 10 rats with TBI and 10 controls). RESULTS: For the in vitro work, clinically relevant concentrations of HTS (2.5% dilution) shortened time to clot formation and increased clot strength (maximum amplitude) compared with control and NS. With higher HTS dosing (5% and 10% blood dilution), there was progressive prolongation of time to clot formation, decreased angle, and decreased maximum amplitude. In the in vivo study, there was no significant difference in thrombelastography measurements or tail-bleeding times after bolus administration of 23.4% HTS compared with NS at 2.5% blood volume. CONCLUSIONS: At clinically relevant dilutions of HTS, there is a paradoxical shortening of time to clot formation and increase in clot strength in vitro and no significant effects in a murine TBI model. However, with excess dilution, caution should be exercised when using serial HTS boluses in TBI patients at risk for trauma-induced coagulopathy.


Assuntos
Coagulação Sanguínea/efeitos dos fármacos , Hipertensão Intracraniana/sangue , Hipertensão Intracraniana/tratamento farmacológico , Solução Salina Hipertônica/farmacologia , Solução Salina Hipertônica/uso terapêutico , Animais , Lesões Encefálicas Traumáticas/complicações , Modelos Animais de Doenças , Feminino , Humanos , Hipertensão Intracraniana/etiologia , Masculino , Ratos Sprague-Dawley , Autorrelato , Tromboelastografia , Fatores de Tempo
15.
Cochrane Database Syst Rev ; 12: CD010904, 2019 12 30.
Artigo em Inglês | MEDLINE | ID: mdl-31886900

RESUMO

BACKGROUND: Increased intracranial pressure (ICP) has been shown to be strongly associated with poor neurological outcomes and mortality for patients with acute traumatic brain injury (TBI). Currently, most efforts to treat these injuries focus on controlling the ICP. Hypertonic saline (HTS) is a hyperosmolar therapy that is used in traumatic brain injury to reduce intracranial pressure. The effectiveness of HTS compared with other ICP-lowering agents in the management of acute TBI is still debated, both in the short and the long term. OBJECTIVES: To assess the comparative efficacy and safety of hypertonic saline versus other ICP-lowering agents in the management of acute TBI. SEARCH METHODS: We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library, PubMed, Embase Classic+Embase (OvidSP), ISI Web of Science: Science Citation Index and Conference Proceedings Citation Index-Science, as well as trials registers, on 11 December 2019. We supplemented these searches using four major Chinese databases on 19 September 2018. We also checked bibliographies, and contacted study authors to identify additional studies. SELECTION CRITERIA: We sought to identify all randomised controlled trials (RCTs) of HTS versus other intracranial pressure-lowering agents for people with acute TBI of any severity. We excluded cross-over trials as incompatible with assessing long term outcomes. DATA COLLECTION AND ANALYSIS: Two review authors independently screened search results to identify potentially eligible trials and extracted data using a standard data extraction form. Outcome measures included: mortality at end of follow-up (all-cause); death or disability (as measured by the Glasgow Outcome Scale (GOS)); uncontrolled ICP (defined as failure to decrease the ICP to target and/or requiring additional intervention); and adverse events (AEs) (e.g. rebound phenomena; pulmonary oedema; acute renal failure during treatment). MAIN RESULTS: Six trials, involving data from 295 people, met the inclusion criteria. The majority of participants (89%) had a diagnosis of severe TBI. We had concerns about particular domains of risk of bias in each trial, as physicians were not reliably blinded to allocation, two trials contained participants with conditions other than TBI and in one trial, there were concerns about missing data for important outcomes. The original protocol was available for only one study and other trials (where registered) were registered retrospectively. Meta-analysis for both the primary outcome (mortality at final follow up) and for 'poor outcome' as per conventionally dichotomised GOS criteria, was only possible for two studies. Synthesis of long-term outcomes was inhibited by the fact that two ceased data collection within two hours of a single bolus dose of an ICP-lowering agent and one at discharge from ICU. Only three studies collected data after release from hospital. Due to variation in modes of drug administration, follow-up times, and ways of reporting changes in ICP, as well as no uniform definition of 'uncontrolled ICP', we did not perform meta-analysis for this outcome and report results narratively, by individual trial. Trials tended to report both treatments to be effective in reducing elevated ICP but that HTS had increased benefits, usually adding that pretreatment factors need to be considered (e.g. serum sodium and both system and brain hemodynamics). No trial provided data for our other outcomes of interest. Evidence for all outcomes is considered very low, as assessed by GRADE. All conclusions were downgraded due to imprecision (small sample size), indirectness (due to choice of measurement and/or selection of patients without TBI), and in some cases, risk of bias and inconsistency. Only one of the included trials reported data on adverse effects (AEs) - a rebound phenomenon, which was present only in the comparator group (mannitol). No data were reported on pulmonary oedema or acute renal failure during treatment. On the whole, investigators do not seem to have rigorously sought to collect data on AEs. AUTHORS' CONCLUSIONS: This review set out to find trials comparing HTS to a potential range of other ICP-lowering agents, but only identified trials comparing it with mannitol or mannitol in combination with glycerol. Based on limited data, there is weak evidence to suggest that HTS is no better than mannitol in efficacy and safety in the long-term management of acute TBI. Future research should be comprised of large, multi-site trials, prospectively registered, reported in accordance with current best practice. Issues such as the type of TBI suffered by participants and concentration of infusion and length of time over which the infusion is given should be investigated.


Assuntos
Lesões Encefálicas Traumáticas/fisiopatologia , Lesões Encefálicas/fisiopatologia , Hipertensão Intracraniana/tratamento farmacológico , Solução Salina Hipertônica/uso terapêutico , Escala de Resultado de Glasgow , Humanos , Hipertensão Intracraniana/etiologia , Avaliação de Resultados em Cuidados de Saúde , Ensaios Clínicos Controlados Aleatórios como Assunto
16.
J Pak Med Assoc ; 69(11): 1741-1745, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31740892

RESUMO

OBJECTIVE: To determine the clinical outcome and mean length of hospital stay of paediatric patients with severe blunt traumatic head injury (THI) receiving 3% hypertonic saline (HTS) in the Emergency Department (ED). Methodology: This case series study was conducted at the Department of Emergency Medicine, Aga Khan University Hospital, Karachi, from 2014 to 2015 via chart review of 105 patients. Detailed history and clinical examination of all paediatric patients aged 2-16 years was recorded which included moderate to severe head injury as classified by the Glasgow Coma Scale (GCS) by the Brain Trauma Foundation. As per routine care after admission of such a patient, for resuscitation 3% HTS was administered. GCS was recorded at 6 hours and at the time of discharge. RESULTS: Of the 105 patients, 76 (72.4%) were male and 29 (27.6%) were female, and the mean age was 61.6+45.9 months. Traumatic brain injury (TBI) was found moderate in 60 (57.1%) cases and severe in 45 (42.9%) of our patients as per the GCS. Six hours after resuscitation with 3% hypertonic saline, 45 (43%) patients normalised as per GCS, 39 (37%) patients had moderate TBI and 21 (20%) had severe TBI. Forty five patients had a hospital stay of 2-3 days. The GCS improved after resuscitation with 3% hypertonic saline in emergency department, with a mean length of stay of 4.6+3.9 and 12.6+10.7 days in moderate and severe head injury respectively with a P value of <0.001, and was normal in 94 (89.5%) patients at the time of discharge. CONCLUSIONS: Paediatric patients with TBI receiving 3% hypertonic saline results in improved GCS and a decrease in the length of hospital stay.


Assuntos
Lesões Encefálicas Traumáticas , Solução Salina Hipertônica , Adolescente , Lesões Encefálicas Traumáticas/epidemiologia , Lesões Encefálicas Traumáticas/terapia , Criança , Pré-Escolar , Serviço Hospitalar de Emergência , Feminino , Escala de Coma de Glasgow , Humanos , Lactente , Tempo de Internação/estatística & dados numéricos , Masculino , Ressuscitação/métodos , Estudos Retrospectivos , Solução Salina Hipertônica/administração & dosagem , Solução Salina Hipertônica/uso terapêutico , Centros de Atenção Terciária , Resultado do Tratamento
17.
Lakartidningen ; 1162019 Oct 22.
Artigo em Sueco | MEDLINE | ID: mdl-31638709

RESUMO

The first studies of treatment of bronchiolitis in infants and toddlers with inhalation of hypertonic saline showed that the treatment was beneficial but later studies have challenged these results. Here, we review four systematic reviews from 2015-2017 and two more recent studies not included in the reviews. Our conclusions are that in moderately severe bronchiolitis, the benefits of treatment are small or absent and inhalations should not be routine. In severe cases, inhalation of hypertonic saline may be considered but benefits are not proven. Water is an irritant to the lower respiratory tract and saline is therefore doubtful as a placebo. We found only one study with conservative placebo (no inhalation). It showed no benefit of hypertonic NaCl and should be repeated.


Assuntos
Bronquiolite/tratamento farmacológico , Solução Salina Hipertônica , Doença Aguda , Administração por Inalação , Pré-Escolar , Humanos , Lactente , Nebulizadores e Vaporizadores , Solução Salina Hipertônica/administração & dosagem , Solução Salina Hipertônica/uso terapêutico , Revisões Sistemáticas como Assunto , Resultado do Tratamento
18.
J Dairy Sci ; 102(12): 11337-11348, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31606222

RESUMO

Neonatal diarrhea remains the primary cause of mortality in dairy calves around the world, and optimal treatment protocols are needed. The main goals of therapy are to restore hydration and electrolyte concentrations, correct strong ion (metabolic) acidemia, and provide nutritional support. Administration of oral electrolyte solutions (OES) has long been the primary method used to treat neonatal diarrhea in humans and calves because OES are capable of addressing each of the primary goals of therapy. In calves with moderate dehydration, we hypothesized that oral electrolytes would be as good as or better than small volumes of intravenous (IV) or subcutaneous (SC) fluids. Therefore, the main goal of this study was to compare the ability of a commercially available oral electrolyte solution (OES) administered alone or in combination with hypertonic saline with small volumes of IV or SC fluid therapy to resuscitate calves with diarrhea. Thirty-three Holstein calves from 5 to 14 d of age were utilized in this clinical trial. Diarrhea and dehydration were induced by adding sucrose to the milk replacer. In addition, hydrochlorothiazide and spironolactone were given orally and furosemide intramuscularly. Depression status, clinical hydration scores, fecal consistency, and body weight were recorded at regular intervals. Treatment began when calves had severe diarrhea and had a decrease in plasma volume of at least 10%. Calves were randomly assigned to 1 of 4 treatment groups of 8 to 9 calves per group: (1) OES; (2) OES with hypertonic saline (4 mL/kg, IV); (3) IV fluids (lactated Ringer's, 2 L); or (4) SC fluids (lactated Ringer's, 2 L). Treatments were given at 0 and 12 h. Changes in plasma volume, blood pH, electrolyte levels, and physical examination scores were determined before therapy and again at 1, 2, 4, 8, and 12 h after each treatment. All 4 treatments were ultimately successful in improving hydration as well as increasing blood pH; however, animals in both groups that received OES had much faster resuscitation than those in either the IV or SC fluid group. In conclusion, oral electrolyte products remain the gold standard for resuscitating diarrheic calves with moderate dehydration and acidemia and will likely perform better than small volumes of IV lactated Ringer's solution. Subcutaneous fluids by themselves are a poor treatment option and should be only be used as supportive therapy following the initial correction of hypovolemia and metabolic acidosis.


Assuntos
Doenças dos Bovinos/terapia , Diarreia/veterinária , Hidratação/veterinária , Solução Salina Hipertônica/uso terapêutico , Administração Intravenosa , Animais , Animais Recém-Nascidos , Peso Corporal , Bovinos , Doenças dos Bovinos/tratamento farmacológico , Desidratação/terapia , Desidratação/veterinária , Diarreia/terapia , Eletrólitos/administração & dosagem , Fezes , Infusões Subcutâneas , Concentração Osmolar , Volume Plasmático , Solução Salina Hipertônica/administração & dosagem
19.
Med Sci Monit ; 25: 8120-8130, 2019 Oct 30.
Artigo em Inglês | MEDLINE | ID: mdl-31662580

RESUMO

BACKGROUND Our previous study found a novel fluid combination with better resuscitation effects under hypotensive condition at the early stage of uncontrolled hemorrhagic shock (UHS). However, the optimal recovery concentration of hypertonic saline in this fluid combination remains unknown. This experiment aimed to explore the optimal concentration. MATERIAL AND METHODS New Zealand white rabbits (n=40) were randomly divided into 5 groups, including a sham-operated group (SO), a shock non-treated group (SNT), a normal saline group (NS), and hypertonic saline groups (4.5% and 7.5%). We established an UHS model and administered various fluid combinations (dose-related sodium chloride solution+crystal-colloidal solution) to the groups followed by monitoring indexes of hemodynamic and renal function, measuring infusion volume and blood loss, and analyzing pathological morphology by hematoxylin and eosin staining. RESULTS The hypertonic saline groups showed more stable hemodynamic indexes, reduced blood loss, fewer required infusions, and milder decreases in renal function than those of control groups (SNT and NS groups), and exhibited fewer pathological changes in the heart, lung, kidney, and liver. All indexes in the 4.5% and 7.5% groups were better than those of the NS group, and the hemodynamic indexes in the 7.5% group were more stable than those of the 4.5% group (P<0.05), with reduced blood loss and infusion volume and a milder decrease in renal function. CONCLUSIONS The novel fluid combination with 7.5% hypertonic saline group had a better recovery effect at the early stage of UHS before hemostasis compared to that of the 4.5% hypertonic saline group. This result may provide guidance for clinical fluid resuscitation.


Assuntos
Solução Salina Hipertônica/uso terapêutico , Choque Hemorrágico/tratamento farmacológico , Cloreto de Sódio/uso terapêutico , Animais , Pressão Sanguínea , Hidratação/métodos , Hemodinâmica , Hipotensão , Masculino , Modelos Animais , Coelhos , Ressuscitação
20.
JAAPA ; 32(10): 48-50, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31567743

RESUMO

Despite the high incidence of hyponatremia, the correct approach to management, particularly in patients with severe hyponatremia (serum sodium of 120 mEq/L or less), is controversial. This article reviews two major consensus guidelines and recent studies that can help clinicians make evidence-based treatment decisions and reduce patient risk for iatrogenic osmotic demyelination from overly aggressive treatment.


Assuntos
Hiponatremia/terapia , Solução Salina Hipertônica/uso terapêutico , Doenças Desmielinizantes/induzido quimicamente , Doenças Desmielinizantes/prevenção & controle , Gerenciamento Clínico , Humanos , Doença Iatrogênica/prevenção & controle , Guias de Prática Clínica como Assunto , Medição de Risco
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