Mannitol versus hypertonic saline for brain relaxation in patients undergoing craniotomy

Abstract

BACKGROUND: Patients with brain tumour usually suffer from increased pressure in the skull due to swelling of brain tissue. A swollen brain renders surgical removal of the brain tumour difficult. To ease surgical tumour removal, measures are taken to reduce brain swelling, often referred to as brain relaxation. Brain relaxation can be achieved with intravenous fluids such as mannitol or hypertonic saline. This review was conducted to find out which of the two fluids may have a greater impact on brain relaxation. OBJECTIVES: To compare the effects of mannitol versus those of hypertonic saline on intraoperative brain relaxation in patients undergoing craniotomy. METHODS: Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 10), Medline via Ovid SP (1966 to October 2013) and Embase via Ovid SP (1980 to October 2013). We also searched specific websites, such as www.indmed.nic.in, www. cochrane-sadcct.org and www.Clinicaltrials.gov. Selection criteria: We included randomized controlled trials (RCTs) that compared the use of hypertonic saline versus mannitol for brain relaxation. We also included studies in which any other method used for intraoperative brain relaxation was compared with mannitol or hypertonic saline. Primary outcomes were longest follow-up mortality, Glasgow Outcome Scale score at three months and any adverse events related to mannitol or hypertonic saline. Secondary outcomes were intraoperative brain relaxation, intensive care unit (ICU) stay, hospital stay and quality of life. Data collection and analysis: We used standardized methods for conducting a systematic review, as described by the Cochrane Handbook for Systematic Reviews of Interventions. Two review authors independently extracted details of trial methodology and outcome data from reports of all trials considered eligible for inclusion. All analyses were made on an intention-to-treat basis. We used a fixed-effect model when no evidence was found of significant heterogeneity between studies, and a random-effects model when heterogeneity was likely. MAIN RESULTS: We included six RCTs with 527 participants. Only one RCT was judged to be at low risk of bias. The remaining five RCTs were at unclear or high risk of bias. No trial mentioned the primary outcomes of longest follow-up mortality, Glasgow Outcome Scale score at three months or any adverse events related to mannitol or hypertonic saline. Three trials mentioned the secondary outcomes of intraoperative brain relaxation, hospital stay and ICU stay; quality of life was not reported in any of the trials. Brain relaxation was inadequate in 42 of 197 participants in the hypertonic saline group and in 68 of 190 participants in the mannitol group. The risk ratio for brain bulge or tense brain in the

Definition, evaluation, and management of brain relaxation during craniotomy

“…66 Overall, the current evidence does not support choosing one agent over the other, especially given the lack of long-term outcome data. 67 Furosemide is another agent that is often used alone or in combination with a hyperosmolar agent to treat a tight brain. Although earlier animal data suggested that furosemide acts synergistically with mannitol to reduce brain water content, 50 more recent studies demonstrated that furosemide does not reduce the brain water content even in combination with mannitol, 68 and its addition to hypertonic saline does not significantly augment the cerebral dehydration effect in comparison with that using hypertonic saline alone.…”

Effect of Albumin in Combination With Mannitol on Whole-blood Coagulation In Vitro Assessed by Thromboelastometry

“…Although current neurotrauma guidelines recommend mannitol for trauma patients with elevated intracranial pressure, 24 hypertonic saline has been shown to be at least as effective 25 or even better 26 than mannitol in reducing brain swelling, and from a hemostatic point of view hypertonic saline might be more suitable than mannitol in neurosurgery or neurointensive care. 3 So, whenever a possible coagulopathy is suspected during craniotomy, the coadministration of albumin and mannitol should be considered cautiously, especially because hypertonic saline seems to be safer alternative to mannitol.…”

Oncologic emergencies and urgencies: A comprehensive review

“…• Although hypertonic (3%) saline or mannitol can be used emergently to create an osmotic gradient across the blood-brain barrier, the priority is alleviating the mass effect (Prabhakar 2014 58 ).…”