Mannitol and hypertonic saline in Subdural hematoma

Slides:



Advertisements
Similar presentations
Rapid Reversal of Warfarin Therapy in Patients with Intracranial / Intraspinal Bleeding Mount Auburn Hospital Blood Bank, Emergency Department, Critical.
Advertisements

Stroke Workshop Case Scenario.
STATUS ASTHMATICUS Sigrid Hahn, MD Andy Jagoda, MD, FACEP Department of Emergency Medicine Mount Sinai School of Medicine New York, New York.
Traumatic Brain Injury Children Torsten Lauritsen Rigshospitalet Copenhagen.
Diuretic Strategies in Patients with Acute Decompensated Heart Failure Diuretic Optimization Strategies Evaluation (DOSE) trial.
Electrolyte management in the PICU Goals To discuss the pathophysiology of electrolyte disturbances To review the acute management of electrolyte.
Fluid & Electrolyte Imbalance
Electrolyte and Metabolic Disturbances AHMED GHALI MD.
Katie Clement, MD PICU Resident Lectures 2011 Traumatic Brain Injury.
The Society of Neurological Surgeons Bootcamp The Society of Neurological Surgeons Bootcamp ICP Management.
Intracranial hematomas
SEPSIS KILLS program Adult Inpatients
Epilepsy 2 Dr. Hawar A. Mykhan.
Severe Traumatic Brain Injury Andy Jagoda, MD, FACEP.
Edward P. Sloan, MD, MPH, FACEP Diagnosing & Treating Emergency Department CNS Hemorrhage Patients.
Case Presentation: BLS to ALS Handoff 21 year old male Unrestrained driver, single vehicle MVC 20mph; sedan vs. concrete barrier No airbag Starred windshield.
HYPONATREMIA & HYPERNATREMIA
Severe Sepsis Initial recognition and resuscitation
Herniation: Compartment Syndrome of the Head Connie Chen, MD Neurology Consultants of Dallas.
Traumatic Brain Injury Case Scenario Workshop Maurizio Berardino Neuroanesthesia and Intensive Care Neuroscience Department San Giovanni Battista Hospital.
Mannitol in Head Trauma: Controversy, Data, and Implications for Evidence-Based Neurosurgery Maya Babu.
Physiology of Hyponatremia Hyponatremia results from either the excessive intake or inability to excrete free water. Water intake  dilutional fall in.
An Overview of Head Injury Management Eldad J. Hadar, M.D. Department of Neurosurgery.
Neurological Emergencies Dr. Amal Alkhotani MBBCH, FRCPC, Epilepsy and EEG.
Non-pharmacological interventions in traumatic brain injury: an update Dr Matt Wiles Department of Neuroanaesthesia & Neurocritical Care Sheffield Teaching.
Increase Intracranial Pressure
Loop diuretics VS venous ultrafiltration in cardio-renal syndrome Radek Debiec SHO Renal Medicine LGH Sept 2013.
Copyright 2008 Society of Critical Care Medicine Management of Life- Threatening Electrolyte and Metabolic Disturbances.
Edward P. Sloan, MD, MPH, FACEP Diagnosing & Treating ED CNS Hemorrhage Patients.
By: Janel Canty RNS (Osborn, 2010). Objectives To understand Hyponatremia To be able to recognize hyponatremia in a clinical setting Be able to apply.
Scott Weingart, MD Optimizing ED Management of Severe Traumatic Brain Injury: A Diagnosis & Treatment Protocol.
Care of the Anti-coagulated Trauma Patient Julie Mayglothling, MD, FACEP Emergencies in Medicine March 8 th, 2012.
Intracerebral Haemorrhage. Clinical Context ICH accounts for up to 15% of first-time strokes and is associated with a 30-day mortality rate between 35%
Progesterone and Traumatic Brain Injury. from: Progesterone is a female hormone important for the regulation of.
Intracranial Pressure (ICP) Megan McClintock, MS, RN Megan McClintock, MS, RN11/4/11.
Michelle Biros, MD Evaluation & Management of Severe Traumatic Brain Injury Patients with Suspected Elevated ICP.
Severe Pediatric Head Injury – tips and tricks Jonathan Duff MD Division of Pediatric Critical Care University of Alberta.
Management. Goals of emergency management for status epilepticus Ensure adequate brain oxygenation and cardiorespiratory function Terminate clinical and.
Emergency anticoagulant reversal B Vigué, DAR, CHU Bicêtre.
Fluid Resuscitation in the ER
Stroke and the ED Kurian Thomas, MD Department of Neurology.
FERNE/EMRA How do we treat ICH patients with an elevated INR Andy Jagoda, MD, FACEP Professor and Vice Chair Department of Emergency Medicine Mount Sinai.
Chapter 23 - IV Fluids and Electrolytes Seth Christian, MD MBA Tulane University Hospital and Clinic Seth Christian, MD MBA Tulane University Hospital.
Subdural Hematoma By Sean Stives. What is it? Subdural = beneath (visceral to) the dura Hematoma = a blood clot Damage caused by increased pressure on.
Najwa Al-Bustani Neurology PGY-3. INTRACEREBRAL HEMORRHAGE: Bleeding into the parenchyma of the brain that may extend into the ventricles and, in rare.
Treatment of Ischaemic Stroke The American Heart Association American Stroke Association Guidelines Stroke. 2007;38:
E Stanton RN MSN/ED, CEN, CCRN, CFRN
Fluid and Electrolyte Imbalance Acid and Base Imbalance
Case 60 F with PMH HTN, DM, CVA presented to UNC ED CC: seizure. Per the daughter the pt was walking and all of a sudden fell and her whole body started.
Severe Traumatic Brain Injury Scott Silvers, MD, FACEP.
MANAGEMENT. General Initial Management 1.assessment and control of the airways and of ventilation, 2.ABG, ECG and blood pressure monitoring. 3.Other measures.
Managing Increased Intracranial Pressure. Introduction The cranium is a rigid compartment. Contains the brain, vessels and cerebrospinal fluid. Can not.
Salt or Sugar: Hypertonic Saline versus Mannitol
{ Challenging Case Presentations From South Texas Methodist Hospital REGIONAL SYSTEMS OF CARE DEMONSTRATION PROJECT: MISSION: LIFELINE™ STEMI SYSTEMS ACCELERATOR.
A pilot randomized controlled trial Registry #: NCT
Hyponatremia. Definition Serum [Na] < 135 meq/L Serum [Na] < 135 meq/L - incidence is 1%-4% Serum [Na] < 130meq/L - incidence is 15%-30% (represents a.
Journal club 24/10/2016 Presented by Pitchayud Kantachuvesiri
Rapid Reversal of Warfarin Therapy in Patients with Intracranial / Intraspinal Bleeding Mount Auburn Hospital Blood Bank, Emergency Department, Critical.
Warfarin Toxicity Treatment & Management
Cerebral Oedema Classification: Vasogenic Oedema Cytotoxic Oedema
Diabetes Ketoacidosis
Evaluation of Four Factor Prothrombin Complex Concentrate
Phillip Howells, Vikram Anumakonda and Nikhil Bhasin
Increased Intracranial Pressure
In the name of God. Management trauma in elderly DR. NIKSOLAT GERIATRICIAN ASSISTANT PROFESSOR, IRAN UNIVERSITY OF MEDICAL SCIENCE.
Performance Improvement: Emergency Management in Acute Cerebrovascular Patients Current US Guidelines Lisa A. Shultz, MD Medical Director, Lourdes Stroke.
Approach to Hemorrhagic and Ischemic Strokes
Fluid Balance, Electrolytes, and Acid-Base Disorders
Paul Szczybor PA-C DFAAPA Lifebridge Critical Care
Clinical Scenario 74-year-old man p/w recent gastroenteritis characterized by n/v/d x 5 days, in addition to fatigue and headache. CT head (-) in ED.
Presentation transcript:

Mannitol and hypertonic saline in Subdural hematoma Briana Santaniello, MBA PharmD Candidate 2015 February 11, 2015

Objectives After reviewing the patient case, the audience should be able to: Recognize the treatment options for a subdural hematoma Describe the mechanisms of action of these agents Analyze available literature comparing the effectiveness of these treatments Determine if current guidelines should be updated to reflect recent literature suggestive of dose change

Meet the patient: MD CC: Unresponsive s/p witnessed fall with subsequent emesis HPI: 83 yo F Sustained witnessed fall Found vomiting by son-in-law Felt unwell & requested to lay down Progressively more somnolent Son-in-law called 9-11. PMH/PSH: sick sinus syndrome s/p pacemaker, HTN, HLD, osteoporosis, hypothyroidism

Meet the patient: MD (continued) FH: unavailable SH: lives with husband who has dementia; babysitter of 3 year old grandchild; has 3 children Allergies: midazolam Reaction – not specified Home medications (doses unknown): warfarin amlodipine levothyroxine simvastatin

Meet the patient: MD (continued) Physical examination/presentation to ED: Somnolent Contusion/laceration to R side of face & bridge of nose Pupils equal and sluggishly reactive (3 mm bilaterally) Vomitus and blood obstructing airway Presents to ED: GCS 9 Decompensation ensued & left pupil became fixed & dilated: GCS 7 Intubation

Vital signs and pertinent information Upon Arrival Decompensation BP (mmHg) 150/84 200/88 O2 sat 97% 88% Pulse (bpm) 105 80 RR (breaths/min) 22 20 POC (mg/dL) 161 ------ INR 2.3

Additional information Height: 162 cm Weight: 66.8 kg Serum creatinine: 0.9 mg/dL Round to 1 based on age > 65 years old Creatinine clearance: 40.9 mL/min

Medications given in ED Decision to intubate fentanyl 100 mcg IV etomidate & rocuronium propofol Signs of impending herniation Contusion to head Pupil blown Decerebrate posturing Suspected subdural hematoma mannitol 100 g IV Sent for CT scan

Results of CT scan Massive holohemispheric subdural hematoma: Left

Treatment of subdural hematoma Craniotomy Burr hole trepanation/trephination Decompressive craniectomy Head elevation at 30° angle Osmotic diuretics/Hyperosmolar therapy Surgical hematoma evacuation Non-pharmacologic *craniotomy has better outcomes (limited observational data) Pharmacologic -Brain Trauma Foundation’s 2007 Guidelines for the Management of Severe Traumatic Brain Injury -Wilkins RH, Rengachary SS. Neurosurgery. 2nd ed. New York:. McGraw Hill;1996:2603-2720

Urgent surgical procedures in anticoagulated patients Reversal of anticoagulant is necessary Immediate cessation of anticoagulants & antiplatelets + vitamin K 10 mg by slow IV infusion or recombinant human factor VIIa (rFVIIa) fresh frozen plasma (FFP) prothrombin complex concentrate (PCC) PCC dose calculated using initial INR and body weight

Pharmacological options MANNITOL HYPERTONIC SALINE Mechanism of action: Mechanism of action osmotic gradient between CSF and subarachnoid space ↓ subarachnoid space pressure ↓ICP osmotic gradient: intracellular fluid moves extracellularly ↑ intravascular blood volume ↑ plasma sodium ↓ brain water Mannitol is a sugar alcohol, filtered by kidney *intracellular volume inversely proportional to plasma sodium concentration* Na+ has reflection coefficient of nearly 1; with intact BBB, little Na+ crosses BBB, so Na+ can pull fluid out of interstitial space Fink ME. Osmotherapy for Intracranial Hypertension: Mannitol Versus Hypertonic Saline. Continuum Lifelong Learning Neurol 20012;18(3):640-654.

Mannitol in subdural hematoma Available formulations: 20% solution 25% in vials Dose: 0.5 to 1 g/kg Doses < 0.5 g/kg: less efficacious, shorter DOA Administration IV bolus over 20 minutes Requires filter crystallization *IV bolus can be given peripherally osmotic gradient tells you actual serum mannitol level and mannitol clearance Fink ME. Osmotherapy for Intracranial Hypertension: Mannitol Versus Hypertonic Saline. Continuum Lifelong Learning Neurol 20012;18(3):640-654.

Mannitol in subdural hematoma (continued) Adverse Effects Electrolyte abnormalities (hypernatremia, hypokalemia, metabolic acidosis) Hypotension Monitoring ICP Serum osmolarity DNE 320 mOsm/L Osmotic gradient: ideally ≥ 10 mOsm Fink ME. Osmotherapy for Intracranial Hypertension: Mannitol Versus Hypertonic Saline. Continuum Lifelong Learning Neurol 2012;18(3):640-654. Mannitol. Package Insert. Baxter Health Care. 2011. Old Toongabbie, NSW.

Mannitol in subdural hematoma (continued) Complications CHF with pulmonary edema Acute renal failure Rebound hypertension with cessation of therapy Contraindications Hypersensitivity Anuria from severe renal disease Severe pulmonary edema, HF Hyperosmolarity prior to initial dose Severe dehydration Metabolic edema Progressive renal disease Fink ME. Osmotherapy for Intracranial Hypertension: Mannitol Versus Hypertonic Saline. Continuum Lifelong Learning Neurol 2012;18(3):640-654. Mannitol. Package Insert. Baxter Health Care. 2011. Old Toongabbie, NSW.

Hypertonic saline in subdural hematoma Available formulations: 2%, 3%, 5%, 7%, 23.4% Less potent diuretic than mannitol ↔ intravascular volume ↑ blood pressure, CO, cerebral blood flow Dose: 5-6 mL/kg bolus dose of 3% administered over 30 minutes Can vary depending on hospital’s protocol Administration IV bolus Preferably administered via central line high concentration Can be administered peripherally in trauma room Maximum of 100 mL/hr for up to 5 hours per site *theoretically can be administered as continuous infusion but time is of the essence in someone with impending herniation so the faster the better* Fink ME. Osmotherapy for Intracranial Hypertension: Mannitol Versus Hypertonic Saline. Continuum Lifelong Learning Neurol 20012;18(3):640-654.

Hypertonic saline in subdural hematoma (continued) Side Effects Hypokalemia supplemental potassium Dehydration Monitoring serum Na+ (ideally < 160 mEq/L or < 180 mEq/L in refractory cases) serum osmolarity (target < 320 mOsmol/L) fluid status (intake/output) body weight CXR (pulmonary edema) Fink ME. Osmotherapy for Intracranial Hypertension: Mannitol Versus Hypertonic Saline. Continuum Lifelong Learning Neurol 20012;18(3):640-654.

Hypertonic saline in subdural hematoma (continued) Complications hyperchloremic acidosis With repeated doses or continuous infusion Central pontine myelinolysis (CPM) Renal failure Cardiac arrhythmias Hemolysis CHF with pulmonary edema Contraindications Chronic hyponatremia (i.e. SIADH) due to risk of CPM Fink ME. Osmotherapy for Intracranial Hypertension: Mannitol Versus Hypertonic Saline. Continuum Lifelong Learning Neurol 20012;18(3):640-654.

Mannitol vs. hypertonic saline Double Blind Study of Hypertonic Saline vs Mannitol in the Management of Increased Intracranial Pressure (ICP) Study withdrawn prior to enrollment Unfeasible timeline to consent prior to intervention No Class I evidence supporting use of one agent over the other Mortazavi et al: literature review with meta-analysis comparing hypertonic saline to mannitol *Beth Israel Deaconess was withdrawn study*

Mannitol vs. hypertonic saline Mortazavi et al: PubMed literature search of all clinical studies in which HTS was used for elevated ICP 12 compared hypertonic saline with mannitol 7 RCTs, 1 prospective non-randomized study, 4 retrospective studies Results: 3: hypertonic saline not clinically superior to mannitol for ICP reduction/outcome 9: suggested hypertonic saline is clinically superior to mannitol for ICP reduction Mortazavi MM, Romeo AK, Deep A, et al. Hypertonic saline for treating raised intracranial pressure: literature review with meta-analysis. J Neurosurg 2012;116:210-221

Mannitol vs. hypertonic saline Among the 9 trials supporting use of hypertonic saline over mannitol: Total of 236 subjects among the 9 trials Different concentrations of hypertonic saline used in each trial Some trials used continuous infusion; others used bolus dose Conflicting results on mortality in hypertonic saline groups

Hypertonic saline in subdural hematoma (continued) Neurocritical Care Society practice patterns survey mannitol: 45.1% More comfortable with agent, no central venous access required, more effective hypertonic saline: 54.9% Fewer side effects, better long-term benefits, less of a rebound effect, easier titration, less associated with renal failure Mortazavi MM, Romeo AK, Deep A, et al. Hypertonic saline for treating raised intracranial pressure: literature review with meta-analysis. J Neurosurg 2012;116:210-221

high-dose mannitol Randomized trial in 178 comatose adult patients diagnosed with acute traumatic subdural hematoma over 4 year period Randomly assigned to 1 of 2 groups: High-dose mannitol group: 91 patients Conventional-dose mannitol group: 87 patients All were administered 0.6-0.7g/kg mannitol as fast IV infusion, followed by normal saline solution administered via rapid IV infusion at 6-7 mL/kg 25 to 30 minutes later, high-dose mannitol group received additional 0.6-0.7g/kg dose of mannitol when pupillary widening was still observed Cruz J, Minoja G, Okuchi G. Improving Clinical Outcomes from Acute Subdural Hematomas with the Emergency Preoperative Administration of High Doses of Mannitol: A Randomized Trial. Neurosurgery 2001;49(4):864-871.

high-dose mannitol All underwent standard craniotomies with clot removal, received fentanyl and propofol, and had head elevation 30° post-craniotomy Monitored via ECG, pulse oximetry, expired PCO2, ICP, MAP Results: 6 months after acute traumatic brain injury, mortality rates were as follows: High-dose mannitol: 14.3% (13 patients) Conventional-dose mannitol: 25.3% (22 patients) P < 0.01 Overall clinical outcomes significantly better in patients who received high-dose mannitol (p < 0.01) Cruz J, Minoja G, Okuchi G. Improving Clinical Outcomes from Acute Subdural Hematomas with the Emergency Preoperative Administration of High Doses of Mannitol: A Randomized Trial. Neurosurgery 2001;49(4):864-871.

??? Mannitol for MD MD weighs 66.8 kg 1 g/kg x 66.8 kg = 66.8 g MD given 100 g ???

Thoughts on appropriate dose Traditionally dosed 1g/kg CrCl: 40.9 mL/minute Poor prognosis Potential for renal harm balanced with potential for better ICP reduction

Take home points

references 1. Brain Trauma Foundation’s 2007 Guidelines for the Management of Severe Traumatic Brain Injury 2. Wilkins RH, Rengachary SS. Neurosurgery. 2nd ed. New York:. McGraw Hill;1996:2603-2720 3. Fink ME. Osmotherapy for Intracranial Hypertension: Mannitol Versus Hypertonic Saline. Continuum Lifelong Learning Neurol 20012;18(3):640-654. 4.Mannitol. Package Insert. Baxter Health Care. 2011. Old Toongabbie, NSW. 5. Mortazavi MM, Romeo AK, Deep A, et al. Hypertonic saline for treating raised intracranial pressure: literature review with meta-analysis. J Neurosurg 2012;116:210-221 6. Cruz J, Minoja G, Okuchi G. Improving Clinical Outcomes from Acute Subdural Hematomas with the Emergency Preoperative Administration of High Doses of Mannitol: A Randomized Trial. Neurosurgery 2001;49(4):864-871 .

Questions? Thank You!