Hayley A. Tatro

Intermittent doses of mannitol or hypertonic saline are recommended to treat elevated intracranial pressure (ICP). However, it is unclear if one agent is more effective than the other. Previous studies have compared mannitol and hypertonic saline in reduction of ICP, with conflicting results. However, no study thus far has compared 23.4% sodium chloride with mannitol. The objective of this study was to determine the difference in absolute reduction of ICP 60 minutes after infusion of 23.4% sodium chloride versus mannitol. This was a single-center retrospective cohort study that included patients at least 16 years old admitted to the trauma/surgical intensive care unit between August 8, 2016, and August 30, 2018, who received either 23.4% sodium chloride 30 mL and/or mannitol 0.5 g/kg and had an ICP monitor or external ventricular drain in place. The primary outcome was absolute reduction in ICP 60 minutes after infusion of hyperosmolar therapy. In all, 31 patients and 162 doses of hyperosmolar therapy were included in the analysis. There was no statistically significant difference in the primary end point of absolute reduction of ICP 60 minutes after infusion of hyperosmolar therapy comparing 23.4% sodium chloride 30 mL with 0.5 g/kg mannitol (P = 0.2929). There was no statistically significant difference found for any secondary end points. No difference was found for absolute reduction of ICP at 30, 60, and 120 minutes, respectively, after infusion of hyperosmolar agent or time to next elevated ICP. Patient-specific parameters should be used to guide the choice of hyperosmolar agent to be administered.

Objective: The objective of this study is to identify risk factors for the development of refractory status epilepticus (RSE). Methods: This was an IRB-approved, retrospective case control study that included patients admitted with status epilepticus between August 1, 2014, and July 31, 2017. Cases were defined as those with RSE, and controls were those who did not develop RSE. A bivariate analysis was conducted comparing those with RSE and those without RSE. A stepwise logistic regression model was constructed predicting for progression to RSE. Risk factors for progression to RSE were extrapolated from this model. Results: A total of 184 patients met inclusion criteria for the study (99 controls and 49 cases). After adjusting for covariates in the logistic regression, patients with convulsive seizures had a lower odds of developing RSE (odds ratio [OR] = 0.375; 95% CI = 0.148 to 0.951; P = 0.0388). Treatment with benzodiazepines plus levetiracetam had a higher odds of developing RSE (OR = 3.804; 95% CI = 1.523 to 9.499; P = 0.0042). Conclusion and Relevance: This study found that patients with convulsive seizures had a lower odds of developing RSE. In addition, patients treated with benzodiazepines and levetiracetam had a higher odds of developing RSE. This information can be used to potentially identify patients at higher risk of developing RSE, so that treatment can be modified to reduce morbidity and mortality. These results may warrant further investigation into the effectiveness of levetiracetam as a first-line agent for the treatment of SE.