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Vol. 34. Issue 6.
Pages 273-282 (November - December 2023)
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Vol. 34. Issue 6.
Pages 273-282 (November - December 2023)
Clinical Research
Comparison of 20% mannitol and 3% hypertonic saline for intraoperative brain relaxation during supratentorial brain tumour craniotomy in patients with a midline shift
Comparación entre manitol 20% y salino hipertónico 3% para la relajación cerebral intraoperatoria durante craneotomía por tumor cerebral supratentorial en pacientes con desviación de la línea media
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Joaquín Hernández-Palazóna, Paloma Doménech-Asensia, Diego Fuentes-Garcíaa,
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smart10015@hotmail.com

Corresponding author.
, Sebastián Burguillos-Lópeza, Claudio Piqueras-Pérezb, Carlos García-Palencianoa
a Department of Anaesthesia, Hospital Clínico Universitario “Virgen de la Arrixaca, Murcia, Spain
b Department of Neurosurgery, Hospital Clínico Universitario “Virgen de la Arrixaca, Murcia, Spain
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Figures (1)
Tables (6)
Table 1. Demographic characteristics and clinical and radiological findings.
Table 2. Brain relaxation scores.
Table 3. Estimated odds ratios in the multivariate logistics regression model of contributing factors for intraoperative brain swelling.
Table 4. Anaesthetic and surgical data.
Table 5. Comparative data of intraoperative parameters.
Table 6. Postoperative morbidity.
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Abstract
Purpose of the study

A prospective, randomized, double-blind study was designed to assess differences in brain relaxation between 20% mannitol and 3% hypertonic saline (HS) during elective supratentorial brain tumour surgery in patients with midline shift.

Material and methods

Sixty patients undergoing supratentorial craniotomy for tumour resection were enrolled to receive either 5mL/kg of 20% mannitol (n=30) or 3% HS (n=30) administered at skin incision. PCO2 in arterial blood was maintained within 35–40mmHg and arterial blood pressure was controlled within baseline values ±20%. The primary outcome was the proportion of satisfactory brain relaxation. The surgeon assessed brain relaxation on a four-point scale (1=excellent with no swelling, 2=minimal swelling, 3=serious swelling not requiring treatment, 4=severe swelling requiring treatment). Postsurgical intracranial changes determined by imaging techniques, postoperative complications, PACU and hospital stay, and mortality at 30 days were also recorded. Appropriate statistical tests were used for comparison; P<0.05 was considered as significant. This trial was registered in Eudract.ema.europa.eu (#2021-006290-40).

Results

There was no difference in brain relaxation: 2.00 [1.00–2.00] and 2.00 [1.75–3.00] for patients in mannitol and HS groups, respectively (P=0.804). Tumour size (OR: 0.99, 95% CI: 0.99–1.01; P=0.371), peritumoral oedema classification (OR: 0.57, 95% CI: 0.11–2.84; P=0.493), mass effect (OR: 0.86, 95% CI: 0.16–4.87; P=0.864), anaesthesia (OR: 4.88, 95% CI: 0.82–28.96; P=0.081) and midline shift (OR: 5.00, 95% CI: 0.84–29.70; P=0.077) did not have a significant influence on brain swelling in patients treated with either mannitol or HS. No significant differences in perioperative outcomes, mortality and length of PACU and hospital stay were observed.

Conclusions

5mL/kg of 20% mannitol or 3% HS result in similar brain relaxation scores in patients undergoing craniotomy for supratentorial brain tumour with midline shift.

Keywords:
Hypertonic saline
Mannitol
Craniotomy
Brain relaxation
Osmotherapy
Resumen
Objetivos del estudio

Estudio prospectivo, aleatorizado y doble ciego diseñado para evaluar diferencias en la relajación cerebral entre manitol 20% y salino hipertónico (SH) 3% durante cirugía supratentorial electiva por tumor cerebral en pacientes con desviación de línea media.

Material y métodos

Sesenta pacientes sometidos a craneotomía supratentorial para resección tumoral se estudiaron para recibir 5ml/kg de manitol 20% (n=30) o SH 3% (n=30) administrados durante la incisión cutánea. La pCO2 en sangre arterial se mantuvo entre 35-40mmHg y la presión arterial se controló dentro de valores basales±20%. El objetivo principal fue la proporción de relajación cerebral satisfactoria. El cirujano evaluó la relajación cerebral en una escala de 4 puntos (1=excelente sin hinchazón, 2=hinchazón mínima, 3=hinchazón grave que no requiere tratamiento, 4=hinchazón severa que requiere tratamiento). Los cambios intracraneales posquirúrgicos determinados por técnicas de imagen, complicaciones postoperatorias, estancia en reanimación y hospitalaria, así como mortalidad a 30 días fueron registrados. Se usaron test estadísticos para la comparación, siendo considerado p<0,05 como significativo. El ensayo fue registrado en Eudract.ema.europa.eu (#2021-006290-40).

Resultados

No hubo diferencias en la relajación cerebral: 2,00 [1,00-2,00] y 2,00 [1,75-3,00] en los pacientes del grupo manitol y SH respectivamente (p=0,804). El tamaño tumoral (OR: 0,99: IC 95%:0,99-1,01; p=0,371), nivel de edema peritumoral (OR: 0,57; IC 95%:0,11-2,84; p=0,493), efecto masa (OR: 0,86; IC 95%: 0,16-4,87; p=0,864), anestesia empleada (OR: 4,88; 95% IC: 0,82-28,96; p=0,081) y desviación de la línea media (OR: 5,00; IC 95%: 0,84-29,70; p=0,077) no tuvieron influencia significativa sobre la hinchazón cerebral en los pacientes de ambos grupos. No hubo diferencias significativas en los resultados perioperatorios, mortalidad ni en estancia en reanimación ni hospitalaria.

Conclusiones

Tanto manitol 20% como SH 3% a 5ml/kg consiguen niveles similares de relajación cerebral en pacientes sometidos a craneotomía para tumor cerebral supratentorial con desviación de la línea media.

Palabras clave:
Salino hipertónico
Manitol
Craneotomía
Relajación cerebral
Osmoterapia

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