Effect of Hypernatremia on the Outcome of Patients with Severe Traumatic Brain Injury

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1 Med. J. Cairo Univ., Vol. 83, No. 2, June: 35-39, Effect of Hyernatremia on the Outcome of Patients with Severe Traumatic Brain Injury TAMER A. HELMY, M.D.; SHERIF ABD EL-MONEM, M.D. and MAHMOUD OMRAN, M.Sc. The Deartment of Critical Care Medicine, Faculty of Medicine, Alexandria University, Egyt Abstract Background: Traumatic Brain Injury (TBI) causes a severe toll on society. TBI is a leading cause of mortality and morbidity worldwide, and the major cause of disability among children and young adults. Material and Methods: This study was conducted on 90 atients of both sexes with diagnosis of severe TBI resented to the Emergency Deartment (ER) and Critical Care Medicine Deartment, Faculty of Medicine, University of Alexandria. Patients were categorized according to the level of serum Na: Mild hyernatremia: (Serum Na 150 <155mmol/L), Moderate hyernatremia: (Serum Na 155 <160mmol/L), Sever hyernatremia: (Serum Na 160mmol/L). Results: There was statstically significant negative correlation between severe hyernatremia and mortality in atients with severe TBI. Conclusion: In atients with severe TBI, there is significant correlation between severe hyernatremia and outcome, as severe hyernatremia was associated with increase risk of death and longer ICU stay. Key Words: Hyernatremia Traumatic brain injury Glasgow coma score ICU admission. Introduction TRAUMATIC Brain Injury (TBI) is a leading cause of morbidity and mortality in children and adolescents. Head injuries can be classified based on the degree of severity and the Glasgow Coma score (GCS). Sodium is the major extracellular cation and one of the most imortant osmotically active solutes. Hyernatremia is a water balance disorder encountered in about 6 to 9% of critically ill atients [1]. Patients with severe (TBI) have a high risk of develoing hyernatremia over the course of their ICU stay, due to the coexistence of redisosing Corresondence to: Dr. Tamer A. Helmy, The Deartment of Critical Care Medicine, Faculty of Medicine, Alexandria University, Egyt conditions such as imaired sensorium, altered thirst, central diabetes insiidus (CDI) with olyuria, and increased insensible losses [2]. After brain injury, hyernatraemia is most commonly related to the develoment of (CDI) or the over use of osmotic diuretics such as mannitol [3]. The incidence of DI can be as high as 35% after TBI when it is associated with more severe injury and increased mortality [4]. The diagnostic criteria of (CDI) are the following: Plasma sodium exceeded 150mmol/L in the resence of olyuria of >3L/24h in the acute clinical setting; following an overnight water derivation test or an 8-h observed water derivation test, urine osmolarity was <600m Osmol/kg [5]. There are three degrees of hyernatremia according to serum Na, Mild (150 <155mmol/L), Moderate (155 <160mmol/L), and Severe ( 160 mmol/l). However, there is controversy regarding which degree (s) (mild, moderate, severe) of hyernatremia is associated with risk of death. Aiyagari and his team found that only severe hyernatremia ( 160mmol/L) is an indeendent risk factor for death in atients in the neurosurgical ICU [6]. However, Maggiore found that mild to moderate hyernatremia can also increase the risk for death in atients with severe TBI [7]. The resent study is designed to correlate between the degree of hyernatremia and mortality after 14 and 30 days of ICU stay. Patients and Methods This study was conducted on 90 atients of both sexes with diagnosis of severe TBI resented to the Emergency Deartment (ER) and Critical 35

2 36 Effect of Hyernatremia on the Outcome of Patients with Severe TBI Care Medicine Deartment, Faculty of Medicine, University of Alexandria. Inclusion criteria: Patient with isolated traumatic head injury. Patient GCS 8 or less. Patient aged between years old. Serum Na 150mmol/L. Exclusion criteria: History of renal insufficiency. History of hyertension treatment. Long term use of diuretics or corticosteroids. Diabetes mellitus or ituitary tumor. Sever infection or homodynamic unstablity. Patient undergoes oerative intervention. Study grous: Ninety atients of both sexes with diagnosis of severe TBI resented to the Emergency Deartment (ER) and Critical Care Medicine Deartment, Faculty of Medicine, University of Alexandria were categorized according to the level of serum sodium: Mild hyernatremia: (Serum Na 150 <155 mmol/l). Moderate hyernatremia (serum Na 155 <160 mmol/l). Sever hyernatremia: (Serum Na 160mmol/L). Material and methods: A comlete history includes age, sex, mechanics of trauma and revious medical disease. Comlete clinical examination of the atient, Blood ressure, Temerature, central venous ressure, Heart rate and resiratory rate. Glasgow Coma Scale (GCS) of the atient every 6 hours. Brain CT-scan on admission and when it done for follows-u. Comlete blood count (CBC) every 3 days. Arterial blood gases (ABG) daily. Renal functions (serum creatinin) and serum otassium every other day. Random blood sugar (RBS) every 6 hours. Liver function tests (ALT, AST) every 3 days. Serum sodium (Na) every day. If hyernatremia is diagnosed-as serum Na 150 mmol/l-serum Na will be measured once daily for 30 days of ICU stay. Results Table (1) shows that the studied atients had a mean age of 35.0± 11.8 years. They comrised 79 males (87.8%) and 11 females (12.2%). Modes of trauma include direct head trauma in 18 atients (20.0%), motor car accidents in 52 atients (57.8%) and falling from height in 20 atients (22.2%) (Table 2). The reorted mortality rate in the studied atients was 41.1% (37 out of 90 atients) (Table 3). Table (4) shows that non survivor atients had significantly higher utilization of mannitol and Hyertonic Saline and had worse degree of hyernatremia and Glasgow coma score. Table (5) shows that non survivor atients had significantly higher serum sodium and lower serum otassium levels. Table (6) shows a significant correlation between serum sodium and serum createnine levels. Table (7) shows no significant differences between different CT diagnosis regarding serum sodium levels. Table (8) shows sever hyernatremia and serum otassim are significant redictors of mortality. Table (1): Demograhic data of the studied atients (n=90). Age (years): Range Mean ± SD 35.0± 11.8 Gender: Male 79 (87.8%) Female 11 (12.2%) Table (2): Mode of trauma of the studied atients (n=90). Number Percentage % Direct head trauma Motor car accident Falling from height Table (3): The mortality rate in the studied atients (n=90). Number Percentage % Survivors Non-survivors

3 Tamer A. Helmy, et al. 37 Table (4): Relation of clinical and theraeutic data to mortality in the studied atients (n=90). Survivors Non survivors Male Female 9 2 Mode of trauma: Direct Motor car Falling 11 9 Brain CT: SAH ICH 14 8 SDH 10 7 Brain contusion 9 5 Brain edema 4 7 Mannitol: Used Not used 10 Hyertonic Saline: Used Not used Hyernatremia: Mild Moderate Severe 5 16 Glasgow coma score: Table (5): Relation between the mortality and the laboratory data on admission of the studied atients (n=90). Survivors Non survivors Student t-test Plasma sodium 132.0± ± Plasma otassium 4.3± ± Serum creatinine 1.1± ± Urine outut ±543.8 ±660.8 Table (6): Correlation between Na and other laboratory data in the studied atients (n=90). r Chi-square test Serum sodium Serum otassium Serum creatinine Urine outut Glasgow coma score χ 2 t Table (7): Relation between Na levels and CT brain findings in the studied atients (n=90). Na F Subarachnoid hemorrhage 136.6±4.7 Intracerebral hemorrhage 137.3±5.8 Subdural hemorrhage 136.4± Brain contusion 133.5±6.7 Brain edema 134.8±6.2 Table (8): Logistic regression for redictors of mortality in the studied atients (n=90). OR Mild hyernatremia Moderate hyernatremia Sever hyernatremia Serum otassium Serum creatinine Discussion Traumatic Brain Injury (TBI) is a major global roblem and affects aroximately 10 million eoles annually; therefore has a substantial imact on the health-care system throughout the world [8]. TBI is traditionally classified as mild, moderate, or severe, based on the initial Glasgow Coma Scale (GCS) score recorded in the Emergency Deartment (ED) [9]. Electrolyte derangements are also common after neurologic injury, with many having neurologic manifestations. In addition, the role of electrolyte abnormalities in the secondary neurologic injury cascade is being delineated and may offer a otential future theraeutic intervention [10]. Hyernatremia is defined by a serum sodium concentration of more than 145mmol/L and reflects a disturbance of the regulation between water and sodium. The high incidence of hyernatremia in atients with severe brain injury is due various causes including oor thirst, diabetes insiidus, iatrogenic sodium administration, and rimary hyeraldosteronism [11]. It has detrimental effects on various hysiologic functions and was shown to be an indeendent risk factor for increased mortality in critically ill atients [12]. The resent study aimed to correlate between the degree of hyernatremia and mortality after 30 days of ICU stay. To achieve this target, the study recruited 90 atients with traumatic head injury. They were subjected to careful history taking, thorough clinical

4 38 Effect of Hyernatremia on the Outcome of Patients with Severe TBI examination and laboratory investigations including CBC and serum electrolytes including Na and K. In the current study, the studied atients had a mean age of 35.0 ± 11.8 years. They comrised 79 males (87.8%) and 11 females (12.2%). This is in accordance with the study of Alali et al., who reorted a marked male redominance in their study on 1,811 atients with traumatic brain injury. The study reorted a female ercent of 25.7% versus 74.3% for females [13]. Modes of trauma in the studied atients include direct head trauma in 18 atients (20.0%), motor car accidents in 52 atients (57.8%) and falling from height in 20 atients (22.2%). This is in harmony with the study of Okasha et al., who evaluated rediction of outcome in 60 consecutive adult atients with TBI admitted to the Alexandria Main University Hosital intensive care units (ICU). In their study, motor car accidents constitutes the main mechanism of injury in the studied atients [14]. The reorted mortality rate in the studied atients was 41.1% (37 out of 90 atients). This rate was comarable to that reorted by the study of Shehata et al., found mortality rate in severe TBI atients with hyernatremia was 36% [15]. In another study, Walder et al., determined the incidence and atients' short-term outcomes of severe traumatic brain injury (stbi) in Switzerland. The hosital mortality was 30.6% (279 of 910 atients) [16]. Regarding the association between the clinical and theraeutic arameters and mortality, our study noted that non survivor atients had significantly higher utilization of mannitol and Hyertonic Saline and had worse degree of hyernatremia and GCS. To assess the relation between hyernatremia and mortality rates, the atients were classified according to the elevation of serum sodium into 3 categories: Mild hyernatremia 42 atients (46.6%), moderate hyernatremia 27 atients (30%) and severe hyernatremia 21 atients (23.2%). The mortality rates for the mild, moderate, and severe hyernatremic grous were 24.3%, 32.4%, and 43.2% resectively; the Odd's ratio was 0.14, 0.39, and 3.02 resectively. In our study only severe hyernatremia (serum sodium > 160) was significantly related with increased mortality in TBI atients. This was in accordance with the study of Aiyagari et al., found that only severe hyernatremia was a risk factor for death [6]. However, that was inconsistent with Maggiore et al., [7] and Li et al., [17] who found that mild, moderate and severe hyernatremia all were associated with increase mortality rate in TBI atients. Another interesting finding in the resent study was the significant association between mortality and lower otassium levels in the TBI atients, the Odd's ratio was This is in agreement with the study of Beal et al., a retrosective trauma registry and chart review was done and found that hyokalemia (K<3.6meq/l) was more frequent in those with closed head injuries and in those who suffered sinal cord injuries [18]. Recently, Wu et al., sought to investigate the revalence, and the relationshi between hyokalemia and the mortality of traumatic brain injury atients. A total 375 cases were included in analysis. The eak incidence of severe hyokalemia occurred in the first 24-96h. TBI atients with severe hyokalemia had significantly higher serum sodium and lower serum hoshorus than those atients with mild or moderate hyokalemia. Comared to other grous, the severe hyokalemia grou had the worst outcome. Moreover, the atients (n=15) who had severe hyokalemia, hyernatremia (Na >160mmol/L), and hyohoshatemia (Ph<0.3 mmol/l) all died in hosital [19]. Conclusion: In atients with severe TBI, there is significant correlation between severe hyernatremia and outcome, as severe hyernatremia was associated with increase risk of death and longer ICU stay. References 1- STELFOX H.T., AHMED S.B., KHANDWALA F., et al.: The eidemiology of intensive care unit acquired hyonatremia and hyernatremia in medical-surgical intensive care units. Crit. Care, 12: 162, TISDALL M., CROCKER M., WATKISS J., et al.: Disturbances of sodium in critically ill adult neurologic atients: A clinical review. J. Neurosurg. Anesthesiol., 18: 57-63, AGHA A., ROGERS B., MYLOTTE D., et al.: Neuroendocrine dysfunction in the acute hase of traumatic brain injury. Clinical Endocrinology, 60: , SHEA A.M., HAMMILL B.G., CURTIS L.H., et al.: Medical costs of abnormal serum sodium levels. Journal of the American Society of Nehrology, 19: , POWNER D.J., BOCCALANDRO C., ALP M.S., et al.: Endocrine failure after traumatic brain injury. Neurocrit. Care, 5: 61-70, AIYAGARI V., DEIBERT E. and DIRINGER M.N.: Hyernatremia in the neurologic intensive care unit: How high is too high? Journal of Critical Care, 21: , 2006.

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