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Hyperosmolar Therapy for Acute Brain Injury: Study Protocol for an Umbrella Review of Meta-­Analyses and an Evidence Mapping

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Hyperosmolar Therapy for Acute Brain Injury: Study Protocol for an Umbrella Review of Meta-­Analyses and an Evidence Mapping Open access Protocol BMJ Open: first published as 10.1136/bmjopen-2019-033913 on 6 February 2020. Downloaded from Hyperosmolar therapy for acute brain injury: study protocol for an umbrella review of meta- analyses and an evidence mapping Rafael Badenes,1,2,3 Brian Hutton ,4,5 Giuseppe Citerio ,6,7 Chiara Robba,8 Gerardo Aguilar,1,3 Adolfo Alonso- Arroyo,9,10 Fabio Silvio Taccone,11 Carlos Tornero,1 Ferrán Catalá-López 3,5,12,13 To cite: Badenes R, Hutton B, ABSTRACT Strengths and limitations of this study Citerio G, et al. Hyperosmolar Introduction Acute brain injury is a challenging therapy for acute brain injury: public health problem worldwide. Elevated intracranial ► This will be the first umbrella review to systemati- study protocol for an umbrella pressure is a common complication after acute brain review of meta-analyses and an cally identify and evaluate the quantity, validity and injury. Hyperosmolar therapy is one of the main evidence mapping. BMJ Open credibility of published meta‐analyses on hyperos- therapeutic strategies for the management of intracranial 2020;10:e033913. doi:10.1136/ molar therapy for acute brain injury. hypertension. This study protocol outlines an umbrella bmjopen-2019-033913 ► Our literature review will be expansive, including review of meta- analyses which will investigate the benefits meta- analyses of randomised controlled trials, ob- ► Prepublication history and and harms of hyperosmolar therapy routinely used for the servational studies or both. additional material for this management of acute brain injury in the intensive care. paper are available online. To ► There may be variability in how treatment inter- Methods and analysis We will search PubMed/ view these files, please visit ventions and outcomes are reported in published MEDLINE, EMBASE and the Cochrane Database of the journal online (http:// dx. doi. meta- analyses, which may pose a challenge in the Systematic Reviews. We will include meta- analyses of org/ 10. 1136/ bmjopen- 2019- qualitative (narrative) synthesis. 033913). primary research studies (eg, randomised controlled ► There may be a paucity in patient- important out- trials, observational studies or both) that evaluate one or comes reported in the published meta- analyses Received 27 August 2019 more hyperosmolar solutions (including hypertonic saline testing the benefits and harms of hyperosmolar Revised 05 December 2019 and/or mannitol) for the treatment of adult patients with therapy. http://bmjopen.bmj.com/ Accepted 22 January 2020 acute brain injury of any severity. Two researchers will independently screen all citations, full- text articles and abstract data. Potential conflicts will be resolved through discussion with a third researcher. Primary outcomes resulting in a large burden of disease in terms will be mortality and neurological outcomes at discharge. of premature death and disability. Compli- Secondary outcomes will include control of intracranial pressure, cerebral perfusion pressure, length of stay cations after acute brain injury cause poor (in hospital an intensive care unit) and any adverse outcomes and enormous losses to individuals, event. Quality of the included meta- analyses will be families and communities. Elevated intracra- on September 28, 2021 by guest. Protected copyright. assessed using the AMSTAR-2 tool. An overall summary nial pressure (ICP) is a common problem in of methods and results will be performed using tabular intensive care units (ICUs), being a poten- and graphical approaches and will be supplemented by tially devastating complication of acute brain narrative description. We will analyse whether published injury. Prevention and control of elevated meta- analyses present an outline of available evidence ICP are the cornerstones of treatment for (eg, cited, described and discussed any previous meta- 4–6 analysis). Where objectives from two or more meta- these patients, as uncontrolled hyperten- analyses overlap, we will assess the causes of any noted sion worsens brain damage and remains the © Author(s) (or their discrepancies between meta- analyses. most common cause of death after the injury. employer(s)) 2020. Re- use Ethics and dissemination No ethical approval will be Several strategies are recommended for the permitted under CC BY-NC. No required. Findings from this study will be published in treatment of elevated ICP in adult patients commercial re- use. See rights a peer- reviewed journal. All data will be deposited in a with acute brain injury.7–9 Currently, hyper- and permissions. Published by cross- disciplinary public repository. BMJ. osmolar therapy with mannitol or hypertonic PROSPERO registration number CRD42019148152. For numbered affiliations see saline solution is the main therapeutic strategy end of article. for the management of intracranial hyperten- sion and cerebral oedema.9 Although hyper- Correspondence to INTRODUCTION Dr Ferrán Catalá-López; Acute brain injury has become a chal- osmolar therapy has been used extensively ferran_ catala@ outlook. com lenging public health problem worldwide,1–3 in routine clinical practice,10–12 significant Badenes R, et al. BMJ Open 2020;10:e033913. doi:10.1136/bmjopen-2019-033913 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-033913 on 6 February 2020. Downloaded from controversy regarding the choice of hyperosmolar agent Eligibility criteria and dosing exists. Detailed eligibility criteria have been developed following Systematic reviews with meta-analyses are prominent the population, interventions, comparators, outcomes tools to guide healthcare decisions and inform research and study design format and are described below. agendas. A growing number of systematic reviews and meta- analyses aiming to evaluate the effects of hyperos- Population molar solutions in acute brain injury have been published This study will include adult patients over the age of showing inconsistent results.13–23 As the number of 18 years admitted to an ICU with an acute primary neuro- published meta- analyses increases, conflicts and divergent logical diagnosis (that is, traumatic brain injury, stroke conclusions among them can emerge producing difficul- or intracerebral haemorrhage) of any severity. Patients ties for decision makers who rely on these studies.24 In with disseminated cerebral disorders (such as meningitis, addition, many meta- analysis authors may not discuss the encephalitis, acute hepatic failure and neoplasms) will be results of previous meta-analyses and systematic reviews.25 excluded. This situation can be confusing for readers and knowl- Interventions and comparators edge users, may contribute to unnecessary duplications The intervention group will be intravenous administra- of meta- analysis26–28 and possibly cause waste in research tion of hyperosmolar therapy routinely used in the ICU, planning, conduct and reporting.29 30 including hypertonic saline at any dose (eg, 3%, 7.5% or This study has been designed to answer the following 23.4% sodium chloride) and mannitol at any dose (e.g. primary research question: what is the effectiveness and ≥20% mannitol) for any duration. The control group safety of hyperosmolar therapy (mannitol and hypertonic could be placebo- controlled, standard of care, no therapy saline) routinely used for the management of acute brain and different therapy (eg, alternative fluid therapy such injury in intensive care? There are three aims within the as 0.9% sodium chloride (normal saline), ≤0.45% sodium planned study. The first aim will be to evaluate the quan- chloride (hypotonic saline), 5% dextrose, Ringer’s lactate, tity, validity and credibility of the evidence from existing Hartmann’s solution). Treatment comparisons of interest systematic reviews and meta‐analyses with regard to the will include hyperosmolar therapy in monotherapy and/ benefits and harms of hyperosmolar therapy for acute or combination therapy regimens against each other or brain injury. The second aim will be to provide a robust against an alternative control group. assessment of the evidence in this area using a revised 31 and improved quality assessment tool: AMSTAR-2. The Outcomes third aim will be to investigate whether published meta- Results on all primary and secondary outcomes of the analyses present an outline of available evidence by refer- included systematic reviews and meta-analyses will be ring to previous meta-analyses and systematic reviews, and reported. However, we will define the following primary http://bmjopen.bmj.com/ compare and contrast findings across overlapping meta- and secondary outcomes for this study. The primary analyses on the same topic. outcomes will be patient-important outcomes including mortality from all causes (defined as 90 day mortality, if not available, 30-day ICU or hospital mortality, whichever METHODS AND ANALYSIS was longest) and neurological outcomes at discharge This review protocol is part of an evidence synthesis project (as reported by authors of included studies, eg, Glasgow on the comparative effectiveness and safety of hyperos- Outcome Scale, extended Glasgow Outcome Scale or molar therapy in neurocritical care. We will conduct an 32 33 modified Rankin Scale). The secondary outcomes will umbrella review (or ‘overview of reviews’), which is on September 28, 2021 by guest. Protected copyright. be ICP (mm Hg), cerebral perfusion pressure (mm Hg), the systematic collection and assessment of multiple any adverse events (as reported by authors of included systematic reviews and meta‐analyses carried
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