Written by Joshua Belfer
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In children with moderate to severe traumatic brain injury (TBI), 3% hypertonic saline (HTS) was not associated with improved survival or better functional outcomes compared to 20% mannitol.
No survival boost with hypertonic saline in kids with TBI
While guidelines favor HTS for elevated intracranial pressure, prior evidence comparing it with mannitol is limited. This large (28 PICUs) multicenter prospective cohort study examined whether 3% hypertonic saline improved mortality or functional outcomes compared to 20% mannitol in children with moderate to severe traumatic brain injury. For the 266 patients who received only one of the agents (184 HTS, 82 mannitol), mortality was 7.1% with HTS and 11.0% with mannitol (P = .34). No significant differences were found in functional outcome scores at discharge (Pediatric Cerebral Performance Category) or at 3 months (Glasgow Outcome Scale–Extended Pediatric Version). Adjusted relative risk for mortality with mannitol vs. HTS was 1.27 (95%CI 0.58–2.66; P = .52).
The observational nature of this study introduces potential bias, given the many confounders that can influence survival in TBI. Additionally, variable use of intracranial pressure monitoring and limited standardization of hyperosmolar therapy across sites may have influenced outcome assessment and comparability.
How will this change my practice?
While prior studies and guidelines have recommended HTS as the first line osmolar treatment for TBI, this large multicenter study suggests both agents yield similar clinical outcomes. There are many clinical and operational factors that may influence a clinician to choose one over the other (i.e. hydration status, availability in code cart vs. pharmacy preparation), but this study suggests that either can be used and yield comparable results. For many of the moderate and severe TBI cases that I will see in the ER, I will likely be engaging my nursing colleagues to determine which medication we can obtain soonest.
Editor’s note: For increased ICP due to infection, I give 3%. Since trauma patients often need volume, instead of a diuretic (i.e. mannitol), I also give 3% in TBI, but that’s just me. ~Clay Smith
Source
Clinical Outcomes of Hypertonic Saline vs Mannitol Treatment Among Children With Traumatic Brain Injury. JAMA Netw Open. 2025 Mar 3;8(3):e250438. doi: 10.1001/jamanetworkopen.2025.0438. PMID: 40067302
