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The level of serum osmolarity at admission in prognosis of nosocomial mortality in patients with severe brain trauma
Maryam Ziaei1, Mehdi Galavi2, Alireza Bahmani2, Ali Abdolrazaghnejad3
1 Department of Emergency Medicine, Khatam-Al-Anbia Hospital, Zahedan University of Medical Sciences, Zahedan, Iran
2 Department of Emergency Medicine, Ali Ibn Abitaleb Hospital, Zahedan University of Medical Sciences, Zahedan, Iran
3 Department of Emergency Medicine, Khatam-Al-Anbia Hospital, Clinical Immunology Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
| Date of Submission | 16-Dec-2021 |
| Date of Acceptance | 12-Feb-2022 |
| Date of Web Publication | 25-Feb-2023 |
Correspondence Address:
Dr. Ali Abdolrazaghnejad
Department of Emergency Medicine, Khatam-Al-Anbia Hospital, Clinical Immunology Research Center, Zahedan University of Medical Sciences, Zahedan
Iran
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/abr.abr_393_21
Background: Traumatic brain injury (TBI) is a leading cause of death among patients in developed countries. The patients' prognosis depends on the trauma-induced primary damage as well as the secondary brain damage, including electrolyte disturbances. Therefore, prevention, diagnosis, and timely treatment lead to better prognosis. Herein, the aim is to prognosticate about the mortality in patients with TBI through serum osmolarity at admission.
Materials and Methods: In this cross-sectional study, 141 patients with TBI were assigned through convenience sampling. The level of serum osmolarity was examined once the patients were admitted to emergency department and later, the outcome was recorded. Finally, we analyzed the relationship between osmolarity level and patient outcome in age groups.
Results: The mean serum osmolarity in the age group of under 18 years, 18 to 60 years, and more than 60 years was equal to 295.3 ± 10.02 mOsm/L, 297.2 ± 6.5 mOsm/L, and 301.6 ± 7.6 mOsm/L, respectively (P-value <0.001). Osmolarity with a cut-off point of more than 298.90 and sensitivity and specificity of 70.49 and 62.86, respectively, had appropriate diagnostic value for predicting mortality in these patients (P-value <0.001).
Conclusion: According to the results of this study, serum osmolarity can have an appropriate diagnostic value in predicting mortality in patients with TBI. In addition, in different age categories, the osmolarity serum in the mortality of these patients was significantly different. Therefore, due to the high importance of serum osmolarity in the mortality of patients, careful monitoring of fluid therapy status of trauma patients should be implemented to prevent the development of hyperosmolarity for the patient with irreversible outcomes.
Keywords: Concussion, Glasgow coma scale, mortality, osmolarity
How to cite this article:
Ziaei M, Galavi M, Bahmani A, Abdolrazaghnejad A. The level of serum osmolarity at admission in prognosis of nosocomial mortality in patients with severe brain trauma. Adv Biomed Res 2023;12:40 |
How to cite this URL:
Ziaei M, Galavi M, Bahmani A, Abdolrazaghnejad A. The level of serum osmolarity at admission in prognosis of nosocomial mortality in patients with severe brain trauma. Adv Biomed Res [serial online] 2023 [cited 2023 Mar 24];12:40. Available from: https://www.advbiores.net/text.asp?2023/12/1/40/370386 |
| Introduction | |  |
Traumatic brain injury (TBI) involves dysfunction of the brain following an external shock.[1],[2],[3] This injury is the major cause of death in developed countries and is increasing in low-income countries. Brain injuries include primary and secondary injuries. Primary injury includes mechanical injuries that occur during a head injury and include brain laceration, hemorrhage, cantogensis, and tissue rupture from the brain, which on microscopic examination is characterized by cell destruction and destruction of very small cerebral vessels. Secondary damage includes a series of intracellular and extracellular disorders (such as hypotension, hypoxia, hyperglycemia, anemia, etc.) that occur at any time of trauma and lead to ion shift and severe depolarization of brain cells.[3],[4]
Patients with brain trauma have different prognoses depending on the severity of the injury. Studies show that the prognosis of these patients depends not only on the primary injury caused by the trauma but also on the secondary brain damage that occurs following the primary injury and sometimes in the course of treatment. In other words, management in the acute phase of the disease and interventions that prevent secondary injuries have significantly reduced the mortality of brain trauma compared with previous decades.[5] It should be noted that only part of the trauma to the skull is due to primary injuries that are not predictable, but most injuries are due to secondary injuries and can be predicted and treated.[6] Given that there are no comprehensive and accurate studies on the frequency of mortality in patients with brain trauma and its relationship with serum osmolarity and the available information is inconsistent, this study aims to investigate the level of serum osmolarity at admission. The prognosis of nosocomial mortality in patients with severe brain trauma was performed during 2017 to 2018.
| Materials and Methods | | |
This study was a cross-sectional study following a diagnostic value approach. The statistical population included all patients with TBI that referred to emergency department (ED) of Khatam al-Anbia Hospital in Zahedan Hospital from March 2017 to March 2018. The sample size of 141 patients was selected from the mentioned population at the confidence interval of 95%, test power of 80%, and based on the results of previous studies[7] indicating the sensitivity of 76%, matching ratio (P) equal to 0.45, and the error level of 0.15. This sample was selected from the target population using the convenience non-probability sampling method.
Patients with isolated brain trauma, those with multiple trauma, and primary head trauma, as well as those with a Glasgow coma scale above 8 were included. Not-inclusion criteria included history of cardiopulmonary disease, renal failure and metabolic disorders, liver disease and coagulopathy, brain disease, use of opium/alcohol and toxication, casualties who presented 6 h after the accident, casualties in the early hours and before 6 h of hospitalization die, the injured ones who have life-threatening trauma to other organs in addition to head trauma, and patients who received normal saline before ED admission.
Due to the fact that some patients usually received intravenous normal saline using fluid therapy before entering the hospital by Emergency medical services, the patient's sodium was not considered primary sodium at admission and it is pre-determined to enroll patients in investigation who have taken pre-hospital normal saline and, secondly, a test from a vein at the farthest point from the patient's serum therapy site.
After approving the code of ethics from the Ethics Committee of Zahedan University of Medical Sciences (number approved: IR.ZAUMS.REC.1396.122) and obtaining written consent from the patient (if was conscious) or patient attendant, first the demographic characteristics of patients including age, sex, serum osmolarity, blood sodium, blood urea nitrogen, and blood sugar were recorded at emergency room. Finally, the number of days of hospitalization and the patient's outcome (death or survival) were registered.
It should be noted that, because serum osmolarity values and response to treatment (resulting in mortality rate) may vary in people under 18 years and over 60 years of age, subjects were assigned to three age groups.
The data were eventually analyzed by SPSS software (version 25, IBM Corporation, Armonk, NY). According to the result of Kolmogorov–Smirnov test for abnormal data distribution, Spearman correlation coefficient and Mann–Whitney test were used. ROC analysis was used to evaluate the diagnostic value of osmolarity in predicting mortality of patients with TBIs. The area under the curve indices, sensitivity and specificity, positive and negative predictive values (PPV and NPV), and positive and negative likelihood ratios (+LR and −LR) were reported. Significance level was also considered less than 0.05.
| Result | | |
Among the 141 patients studied, 100 (70.9%) were male and 41 (29.1%) were female with a mean age of 25.4 ± 16.4 years (ranging in age from 1 to 82 years).
At ED, the mean serum osmolarity levels were 295.3 mOsm/l in under 18-year-old patients, 297.2 mOsm/l in 18- to 60-year-old patients, and 301.6 mOsm/l in over 60 years old ones with TBIs. [Table 1] shows the serum osmolarity, blood sodium, urea nitrogen, and blood sugar in terms of different age groups. | Table 1: Frequency distribution of laboratory values in terms of age groups
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In addition, there was no statistically significant difference between the days of hospitalization of patients with TBIs and serum osmolarity at admission according to Spearman test in the age group of under 18 years (r = −0.132, P = 0.38). Also, this difference was not significant in the age groups of 18 to 60 years (r = −0.102, P = 0.34) and over 60 years (r = 0.46, P = 0.29).
Moreover, the evaluation of the relationship between mortality of patients with TBIs and serum osmolarity in terms of the age of patients showed that 19.6% of patients died under the age of 18 years, 37.5% between the ages of 18 and 60 years, and 28.6% over the age of 60 years. The mean osmolarity in patients under 18 years and 18 to 60 years of age in patients who had died was significantly higher than ones who were alive (P value < 0.001); while in over 60 years old patients, the mean osmolarity in dead patients was significantly lower than in living patients (296.7 ± 12.9 mOsm/L vs 303.7 ± 5.2 mOsm/L; P value <0.001) [Table 2] and [Figure 1]. | Figure 1: Mean osmolarity level in terms of outcome of patients with TBI in different age categories
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 | Table 2: Comparison of mean osmolarity level a in terms of outcome of patients with TBI by age categories
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The cutoff point of osmolarity level in predicting mortality of patients with TBIs was more than 298.90 mOsm/L and the sensitivity and specificity were 70.49% and 62.86%, respectively. Its positive and negative predictive values were 76.81% and 55.00%, respectively (Area under the ROC curve = 0.722, P value <0.001) [Table 3] and [Figure 2]. | Figure 2: ROC curve in the diagnosis of osmolarity level in predicting mortality of patients with TBIs
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 | Table 3: Diagnostic value of osmolarity level in predicting mortality of patients with TBIs
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| Discussion | | |
Electrolyte disturbances are common in patients with concussion,[7],[8] which in turn is an important and controllable cause of nerve damage. Most common disorders are seen in the first week of injury.[1]
This study was performed to determine the relationship between serum osmolarity at admission to the hospital and to predict the hospital mortality of patients with TBIs.
According to the findings, the mean serum osmolarity at the ED was very considerable in under 18 years of age patients with TBIs; because people in this age group have a high risk of mortality if they are hyperosmolar. Prevention of brain injury in this study group is more important than the other two groups, because brain damage in the early stages of life causes irreversible damage to the person and can make it very difficult for them to continue living. Therefore, it is necessary to take special care of this group. Also, in over 60-year-old patients with TBIs, the average serum osmolarity at the ED and their blood sodium are higher than other age groups, which indicates the importance of attention and the need for more care for patients in this age group.
Jabalameli[9] in his study of brain trauma patients in the age group of 3 to 80 years showed that the mean osmolarity was not significantly associated with the severity of brain injury. The minimum and maximum osmolarity in this study was 285 to 274 mOsm/L.
Also according to the results of a study by Balak et al.,[10] in the age group of 1 to 30 years, the mean osmolarity level of patients with minor head trauma and patients with minor trauma in an extremity was not significantly different. But in the age group over 30 years, the mean osmolarity level in patients with minor trauma in an extremity was significantly higher than patients with minor head trauma.
Other studies have recommended that serum osmolarity in brain lesions be kept above the normal range of 285 to 295 mOsm/L[11],[12] which is in agreement with the current study. This can lead to decreased brain fluid and cerebral edema in patients with TBIs and has a better prognosis.[13] However, it should be noted that osmolarity of 260 mOsm/L increases the risk of cerebral edema and Osmotic Demyelination Syndrome, and osmolarity of more than 320 mOsm/L causes cerebral blood vessel disorders and should be treated immediately.[14]
Some studies have suggested that hyponatremia is a common finding in patients with TBIs,[15],[16] which has not been the case in this study. Another study has shown that sodium concentration has no effect on the prognosis of these patients,[17],[18] but studies have shown that administration of hypertonic saline in patients with changes in cranial pressure can reduce cerebral edema and improve the prognosis while keeping plasma sodium higher.[19]
In addition, according to the results of this study, osmolarity with a cut-off point of 298.9 mOsm/L and a sensitivity and specificity of 70.49 and 62.86, respectively, had an appropriate diagnostic value in predicting mortality in patients with TBI. Consistent with this study, in the study of Holtfreter et al.,[7] the cut-off point of osmolality was 298 mOsm/kg with sensitivity and specificity of 76.40 and 61.30, respectively, to predict the mortality of patients admitted to the ICU due to trauma (multiple, brain, chest, or abdominal), surgery (abdominal, chest, or neurosurgery), and other diseases (pulmonary or cardiac decompensation and other disease). In addition to osmolarity, they also evaluated the diagnostic value of other factors such as APACHI II score, SOFA score, sodium, glucose, creatinine, urea, lactate, and procalcitonin in predicting mortality in these patients. However, these factors were not evaluated in present study and could be one of our weaknesses.
According to our findings, in the age groups of under 18 years and 18 to 60 years, the mean osmolarity in the surviving patients was lower than the deaths and this difference was significant. This can indicate the important role of the physician in prescribing the correct fluid therapy and not to increase the serum osmolarity too much in patients with TBIs. High accuracy should be used in regulating the patient's osmolarity and this amount should be monitored with tests to prevent hyperosmolar complications such as severe neurological disorders, acute poisoning, and disorders of the blood-brain barrier. Also, the most important factor in increasing osmolarity in these patients was their high blood sugar during trauma. Therefore, monitoring blood sugar during emergency admission and controlling it can play a vital role in the course of treatment.
Due to some limitations in conducting this study, it is suggested to further increase the reliability of the results; similar study should be conducted with a sample size of over 300. Considering that the status of patients in the present study was followed only in the hospital until their discharge, it is suggested that in future studies, more accurate follow-up be performed on these patients after discharge to determine the possible complications and consequences of the disease. Also, due to the high importance of primary blood sugar in patients with TBIs, blood sugar checks should be added to routine tests of these patients.
| Conclusion | | |
Higher osmolarity resulted in higher mortality in both age groups in this study. The results indicated that due to the high importance of serum osmolarity in patients' mortality, careful monitoring of fluid therapy status of trauma patients should be performed to prevent hyperosmolarity for the patient because it causes irreversible consequences. The treatment team should pay attention to different electrolytes and indicators while maintaining the hemodynamics of the injured person so that they can provide appropriate prognostic care to the patient with TBIs.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Acknowledgements
The present study is derived from the residency dissertation approved by Zahedan University of Medical Sciences (ZUMS) with the ethical code of IR.ZAUMS.REC.1396.122. Therefore, we acknowledge the Vice Chancellor for Research and Technology of ZUMS for financing the research. The authors of the article also express their gratitude to all the professors, assistants, and nurses of the emergency department of Khatam al-Anbia Hospital in Zahedan and others who helped in the implementation of this research.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Pan P, Song Y, Du X, Bai L, Hua X, Xiao Y, et al. Intestinal barrier dysfunction following traumatic brain injury. Neurol Sci 2019;40:1105-10.  |
| 2. | Vedantam A, Robertson CS, Gopinath SP. Morbidity and mortality associated with hypernatremia in patients with severe traumatic brain injury. Neurosurg Focus 2017;43:E2. |
| 3. | Tintinallil JE, John MO, Yealy DM, Meckler GD, Stephan SJ, Cline DM. Tintinalli'sEmergency Medicine: A Comprehensive Study Guide. 9 th ed. USA: McGraw-Hill Education; 2019. |
| 4. | Marx J, Walls R, Hockberger R. Rosen's emergency medicine-concepts and clinical practice e-book. 2013:214-222. |
| 5. | Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GW, Bell MJ, et al. Guidelines for the management of severe traumatic brain injury. Neurosurgery 2017;80:6-15. |
| 6. | Haddad SH, Arabi YM. Critical care management of severe traumatic brain injury in adults. Scand J Trauma Resusc Emerg Med 2012;20:1-15. |
| 7. | Holtfreter B, Bandt C, Kuhn SO, Grunwald U, Lehmann C, Schütt C, et al. Serum osmolality and outcome in intensive care unit patients. Acta Anaesthesiol Scand 2006;50:970-7. |
| 8. | Audibert G, Hoche J, Baumann A, Mertes PM. Water and electrolytes disorders after brain injury: Mechanism and treatment. Ann Fr Anesth Reanim 2012;31:e109-15. |
| 9. | Jabalameli M, Taheri S. Evaluation of plasma sodium, potassium and osmolarity level in patients with head trauma in neurosurgery ICU. Yafte 2011;13:90-8. |
| 10. | Balak N, Isiksacan N, Turkoglu R. Does serum osmolarity change as a result of the reflex neuroprotective mechanism of cerebral osmo-regulation after minor head trauma? J Korean Neurosurg Soc 2017;45:151. |
| 11. | Williams EL, Hildebrand KL, McCormick SA, Bedel MJ. The effect of intravenous lactated Ringer's solution versus 0.9% sodium chloride solution on serum osmolality in human volunteers. Anesthesia & Analgesia 1999;88:999-1003. |
| 12. | Fenn III NE, Sierra CM. Hyperosmolar therapy for severe traumatic brain injury in pediatrics: A review of the literature. J Pediatr Pharmacol Ther 2019;24:465-72. |
| 13. | Froelich M, H?rtl R. Ultra-early hyperosmolar treatment in traumatic brain injury: Will surgery soon be old-school? Crit Care Med 2008;36:642-3. |
| 14. | Bentsen G, Stubhaug A, Eide PK. Differential effects of osmotherapy on static and pulsatile intracranial pressure. Crit Care Med 2008;36:2414-9. |
| 15. | Moro N, Katayama Y, Igarashi T, Mori T, Kawamata T, Kojima J. Hyponatremia in patients with traumatic brain injury. Surg Neurol 2017;68:387-93. |
| 16. | Cole CD, Gottfried ON, Liu JK, Couldwell WT. Hyponatremia in the neurosurgical patient: Diagnosis and management. Neurosurg Focus 2004;16:E9. |
| 17. | Kiaei BA, Farsani DM, Ghadimi K, Shahali M. Evaluation of the relationship between serum sodium concentration and mortality rate in ICU patients with traumatic brain injury. Arch Neurosci 2018;5:1-8. |
| 18. | Dandona R, Kumar GA, Ameer MA, Ahmed GM, Dandona L. Incidence and burden of road traffic injuries in urban India. Inj Prev 2008;14:354-59. |
| 19. | Mangat HS, Wu X, Gerber LM, Schwarz JT, Fakhar M, Murthy SB, et al. Hypertonic saline is superior to mannitol for the combined effect on intracranial pressure and cerebral perfusion pressure burdens in patients with severe traumatic brain injury. Neurosurgery 2020;86:221-30. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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