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Variability in Serum Sodium Concentration and Prognostic Significance in Severe Traumatic Brain Injury: A Multicenter Observational Study

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Abstract

Background/Objective

Dysnatremia is common in severe traumatic brain injury (TBI) patients and may contribute to mortality. However, serum sodium variability has not been studied in TBI patients. We hypothesized that such variability would be independently associated with mortality.

Methods

We collected 6-hourly serum sodium levels for the first 7 days of ICU admission from 240 severe TBI patients in 14 neurotrauma ICUs in Europe and Australia. We evaluated the association between daily serum sodium standard deviation (dNaSD), an index of variability, and 28-day mortality.

Results

Patients were 46 ± 19 years of age with a median initial GCS of 6 [4–8]. Overall hospital mortality was 28%. Hypernatremia and hyponatremia occurred in 64% and 24% of patients, respectively. Over the first 7 days in ICU, serum sodium standard deviation was 2.8 [2.0–3.9] mmol/L. Maximum daily serum sodium standard deviation (dNaSD) occurred at a median of 2 [1–4] days after admission. There was a significant progressive decrease in dNaSD over the first 7 days (coefficient − 0.15 95% CI [− 0.18 to − 0.12], p < 0.001). After adjusting for baseline TBI severity, diabetes insipidus, the use of osmotherapy, the occurrence of hypernatremia, and hyponatremia and center, dNaSD was significantly independently associated with 28-day mortality (HR 1.27 95% CI (1.01–1.61), p = 0.048).

Conclusions

Our study demonstrates that daily serum sodium variability is an independent predictor of 28-day mortality in severe TBI patients. Further prospective investigations are necessary to confirm the significance of sodium variability in larger cohorts of TBI patients and test whether attenuating such variability confers outcome benefits to such patients.

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Acknowledgements

We would ask that the authors be acknowledged individually. Harrois A1,2*, Anstey JR1, van der Jagt M3,Taccone FS4, Udy AA5,15, Citerio G6, Duranteau J2, Ichai C7, Badenes R8, Prowle JR9, Ercole A10, Oddo M11, Schneider A11, Wolf S12, Helbok R13, Nelson DW14, Cooper DJ5,15, Bellomo R1,15,16,17 on behalf of The TBI Collaborative. 1Intensive Care Unit, Level 5, B Block, Royal Melbourne Hospital, Parkville, 3050 Victoria, Australia; 2Department of Anesthesia and Surgical Intensive Care, Paris Sud University, CHU de Bicetre, Le Kremlin Bicêtre, 78, rue du Général Leclerc 94275 Le Kremlin-Bicêtre, France; 3Department of Intensive Care Adults, Erasmus MC-University Medical Center| Dr Molewaterplein 40, 3015 GD, Po Box 2040, 3000 CA Rotterdam, The Netherlands; 4Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium; 5Intensive Care Unit, The Alfred Hospital, Commercial Road, Melbourne, Victoria, Main Ward Block, Level 1, Commercial Rd, Melbourne VIC 3004, Australia; 6School of Medicine and Surgery, University Milano Bicocca - Neurointensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy; 7Université Côte d’Azur, Center hospitalier Universitaire de Nice, Service de Réanimation polyvalente, Hôpital Pasteur 2. 30 Voie Romaine. CHU de Nice. 06000 Nice, France; 8Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, Department of Surgery, University of Valencia, Valencia, Spain; 9Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Royal London Hospital, Whitechapel Road, London E1 1BB, UK; 10Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; 11Department of Medical-Surgical Intensive Care Medicine, Faculty of Biology and Medicine, Center Hospitalier Universitaire, Vaudois (CHUV), University of Lausanne, Lausanne, 1011, Switzerland; 12Department of Neurosurgery, Charité Universitätsmedizin Neuro Intensive Care Unit 102i, Campus Charité Mitte (CCM), Charitéplatz 1, 10117 Berlin, Germany; 13Department of Neurology, Neurocritical Care Unit, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria; 14Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, S-171 76 Stockholm, Sweden; 15Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventative Medicine, Monash University, ANZIC-RC, Department of Epidemiology and Preventive Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne VIC 3004 Australia; 16Department of Intensive Care, Austin Health, 145 Studley Rd, Heidelberg, Melbourne, Victoria, Australia; 17Center for Integrated Critical Care, School of Medicine, University of Melbourne, Melbourne, Australia. We would also ask that the data collectors be acknowledged for their contribution. Long K1, Rodrigues A2, Lozano A4, Saxby E5, Vargiolu A6, Quintard H7, Guillemes M8, Sisson A9, Allen G10, Baro N12, Kofler M13. 1Intensive Care Unit, Level 5, B Block, Royal Melbourne Hospital, Parkville, 3050 Victoria, Australia; 2Department of Anesthesia and Surgical Intensive Care, Paris Sud University, CHU de Bicetre, Le Kremlin Bicêtre, 78, rue du Général Leclerc 94275 Le Kremlin-Bicêtre, France; 3Department of Intensive Care Adults, Erasmus MC-University Medical Center| Dr Molewaterplein 40, 3015 GD, Po Box 2040, 3000 CA Rotterdam, The Netherlands; 4Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium; 5Intensive Care Unit, The Alfred Hospital, Commercial Road, Melbourne, Victoria, Main Ward Block, Level 1, Commercial Rd, Melbourne VIC 3004, Australia; 6School of Medicine and Surgery, University Milano Bicocca - Neurointensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy; 7Université Côte d’Azur, Center hospitalier Universitaire de Nice, Service de Réanimation polyvalente, Hôpital Pasteur 2. 30 Voie Romaine. CHU de Nice. 06000 Nice, France; 8Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, Department of Surgery, University of Valencia, Valencia, Spain; 9Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Royal London Hospital, Whitechapel Road, London E1 1BB, UK; 10Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; 11Department of Medical-Surgical Intensive Care Medicine, Faculty of Biology and Medicine, Center Hospitalier Universitaire, Vaudois (CHUV), University of Lausanne, Lausanne, 1011, Switzerland; 12Department of Neurosurgery, Charité Universitätsmedizin Neuro Intensive Care Unit 102i, Campus Charité Mitte (CCM), Charitéplatz 1, 10117 Berlin, Germany; 13Department of Neurology, Neurocritical Care Unit, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria; 14Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, S-171 76 Stockholm, Sweden; 15Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventative Medicine, Monash University, ANZIC-RC, Department of Epidemiology and Preventive Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne VIC 3004 Australia; 16Department of Intensive Care, Austin Health, 145 Studley Rd, Heidelberg, Melbourne, Victoria, Australia; 17Center for Integrated Critical Care, School of Medicine, University of Melbourne, Melbourne, Australia.

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Correspondence to Anatole Harrois.

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This study followed the STROBE recommendation for observational studies (appendix 1).

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Harrois, A., Anstey, J.R., van der Jagt, M. et al. Variability in Serum Sodium Concentration and Prognostic Significance in Severe Traumatic Brain Injury: A Multicenter Observational Study. Neurocrit Care 34, 899–907 (2021). https://doi.org/10.1007/s12028-020-01118-8

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