All that glitters is not gold?

摘要

In this issue of Critical Care Medicine, Lazaridis et al (1) describe the findings of a systematic review and metaanalysis, "23.4% saline in neurocritical care." In essence, the review found that in a broad range of acute brain injury syndromes, intracranial pressure (ICP) reduction was greater with hypertonic saline (HTS) 23.4% compared with manni-tol (in most instances), at 60 mins or nadir. These data were reported in six studies from which this information could be extracted. Using a fixed-effects model, meta-analysis estimated that the percent decrease in ICP from baseline to either 60 mins or nadir after administration of 23.4% saline was 55.6% (se = 5.90, p < 0.0001,95% confidence interval 43.99, 67.12). This systematic review has assessed "disease-oriented evidence" as it evaluates a physiologic or surrogate marker of health. Improvements in these outcomes do not always lead to improvements in patient-oriented outcomes such as symptoms, morbidity, quality of life, or mortality. Therefore, these impressive se and confidence intervals should not be confused with an effect upon patient-orientated outcomes such as death or disability. Nonetheless, elevated intracranial pressure has consistently been associated with a poor outcome.