A Comparison of 3% Hypertonic Saline and Mannitol for Brain Relaxation During Elective Supratentorial Brain Tumor Surgery

Wu, Ching-Tang; Chen, Liang-Chih; Kuo, Chang-Po; Ju, Da‐Tong; Borel, Cecil O.; Cherng, Chen‐Hwan; Wong, Chih-Shung

doi:10.1213/ane.0b013e3181cb3f8b

Cited by 68 publications

(74 citation statements)

References 28 publications

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“…In line with previous reports [9,35,39,40], our SR confirmed that the administration of HTS heightened the levels of serum sodium, which was sustained for 6 h, and promoted a temporary reduction of potassium [20-22, 24, 26]. In contrast, mannitol caused a transient acute dilutional hyponatremia [20,22,26], with a concomitant stepwise increase of potassium over time [22].…”

Section: Discussionsupporting

confidence: 92%

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Cardiac output changes after osmotic therapy in neurosurgical and neurocritical care patients: a systematic review of the clinical literature

Tsaousi

Stazi

Cinicola

et al. 2018

Brit J Clinical Pharma

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AIMOsmotherapy constitutes a first-line intervention for intracranial hypertension management. However, hyperosmolar solutes exert various systematic effects, among which their impact on systemic haemodynamics is poorly clarified. This review aims to appraise the clinical evidence of the effect of mannitol and hypertonic saline (HTS) on cardiac performance in neurosurgical and neurocritical care patients. METHODA database search was conducted to identify randomized clinical trials and observational studies reporting HTS or mannitol use in acute brain injury setting. The primary end-points were alterations of cardiac output (CO) and other haemodynamic variables, while the impact of osmotic agents on intracranial pressure, brain relaxation, plasma osmolality, electrolyte levels and urinary output constituted secondary outcomes. RESULTSEight studies, enrolling 182 patients in total, were included. HTS exerted a more profound cardiac output augmentation than mannitol, but no distinct difference between groups occurred. Central venous pressure, stroke volume and stroke volume variation were favourably affected by both osmotic agents, whilst the reported changes in blood pressure were inconclusive. HTS infusion yielded a larger intracranial pressure reduction than mannitol but had an equivalent effect on brain relaxation. Mannitol presented a more potent diuretic effect than HTS. Effect on serum osmolality was alike in both osmotic agents, but contrary to HTS-promoted hypernatraemia, mannitol use induced transient hyponatraemia. CONCLUSIONSMannitol or HTS administration seems to induce an enhancement of cardiac performance; being more prominent after HTS infusion. This effect combined with mannitol-induced enhancement of diuresis and HTS-promoted increase of plasma sodium concentration could partially explain the effects of osmotherapy on cerebral haemodynamics. British Journal of Clinical Pharmacology WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT• Osmotherapy with either mannitol or hypertonic saline (HTS) is the recommended first-line medical intervention for optimizing cerebral perfusion through brain relaxation.• Mannitol has long been used as osmotic agent for ensuring brain relaxation in neurosurgical patients undergoing craniotomy, but the clinical benefit of mannitol infusion in acute brain injury setting, has not yet been proven according to evidence-based medicine.• Recent guidelines suggest the use of HTS as a second-line therapy in case mannitol fails to reduce intracranial pressure, in patients sustaining traumatic brain injury. WHAT THIS STUDY ADDS• Both mannitol and HTS induce an increase in cardiac output, which is more pronounced after HTS than mannitol administration.• Mannitol and HTS infusion are associated with a trend towards to mean arterial pressure and heart rate reduction.• Both osmotic agents induced an intracranial pressure reduction and brain relaxation, an effect that seems to be more prominent in HTS-treated patients.

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Section: Discussionsupporting

confidence: 92%

“…While all hyperosmolar agents promote diuresis, HTS exerts a weaker diuretic effect than mannitol, possibly because it stimulates the release of antidiuretic hormones [9,39,40]. By contrast, mannitol infusion could induce hypovolaemia through an increase in diuresis [13,[20][21][22][23][24][25]28].…”

Section: Discussionmentioning

confidence: 99%

Cardiac output changes after osmotic therapy in neurosurgical and neurocritical care patients: a systematic review of the clinical literature

Tsaousi

Stazi

Cinicola

et al. 2018

Brit J Clinical Pharma

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“…However, none of these studies have compared the effects of mannitol and HS on whole blood coagulation. Instead, the focus has been on what effect these two solutions have on ICP, hemodynamics, and acid base balance [8][9][10][11][12][13][14][15]. The results of these studies have been difficult to interpret, and only in one study the osmolarity and the volume have been the same for both solutions [8].…”

Section: Resultsmentioning

confidence: 99%

“…Extensive use of HS can lead to hypernatremia [7]. Earlier studies suggest that HS is equally effective or even better than mannitol in reducing brain swelling in patients undergoing craniotomy [8][9][10][11][12][13][14][15]. However, due to variable study protocols, e.g., regarding osmolarity and administered volumes, definite conclusions about differences in physiological responses or occurrence of untoward effects cannot be drawn.…”

Section: Introductionmentioning

confidence: 99%

Comparison of Hypertonic Saline and Mannitol on Whole Blood Coagulation In Vitro Assessed by Thromboelastometry

et al. 2010

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“…Additionally, the preoperative peritumoral edema and intracranial pressure were not recorded, and only a single dose of mannitol (1 g/kg) was administered. Wu et al [10] compared the effects of 160 mL of 3% hypertonic saline and 150 mL of 20% mannitol on brain relaxation. Their study suggested that 3% hypertonic saline provided better relaxation; however, the lengths of hospital and intensive care unit stays did not significantly differ.…”

Section: Introductionmentioning

confidence: 99%

The effect of mannitol on intraoperative brain relaxation in patients undergoing supratentorial tumor surgery: study protocol for a randomized controlled trial

Peng

Liu

Wang

et al. 2014

Trials

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BackgroundThe risk of brain swelling after dural opening is high in patients with midline shift undergoing supratentorial tumor surgery. Brain swelling may result in increased intracranial pressure, impeded tumor exposure, and adverse outcomes. Mannitol is recommended as a first-line dehydration treatment to reduce brain edema and enable brain relaxation during neurosurgery. Research has indicated that mannitol enhanced brain relaxation in patients undergoing supratentorial tumor surgery; however, these results need further confirmation, and the optimal mannitol dose has not yet been established. We propose to examine whether different doses of 20% mannitol improve brain relaxation in a dose-dependent manner when administered at the time of incision. We will examine patients with preexisting mass effects and midline shift undergoing elective supratentorial brain tumor surgery.MethodsThis is a single-center, randomized controlled, parallel group trial that will be carried out at Beijing Tiantan Hospital, Capital Medical University. Randomization will be achieved using a computer-generated table. The study will include 220 patients undergoing supratentorial tumor surgery whose preoperative computed tomography/magnetic resonance imaging results indicate a brain midline shift. Patients in group A, group B, and group C will receive dehydration treatment at incision with 20% mannitol solutions of 0.7, 1.0, and 1.4 g/kg, respectively, at a rate of 600 mL/h. The patients in the control group will not receive mannitol. The primary outcome is an improvement in intraoperative brain relaxation and dura tension after dehydration with mannitol. Secondary outcomes are postoperative outcomes and the incidence of mannitol side effects.DiscussionThe aim of this study is to determine the optimal dose of 20% mannitol for intraoperative infusion. We will examine brain relaxation and outcome in patients undergoing supratentorial tumor surgery. If our results are positive, the study will indicate the optimal dose of mannitol to improve brain relaxation and avoid side effects during brain tumor surgery.Trial registrationThe study is registered with the registry website http://www.chictr.org with the registration number ChiCTRTRC13003984 (17 December 2013).

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A Comparison of 3% Hypertonic Saline and Mannitol for Brain Relaxation During Elective Supratentorial Brain Tumor Surgery

Abstract: Our results suggest that HTS provided better brain relaxation than did mannitol during elective supratentorial brain tumor surgery, whereas it did not affect ICU stays or hospital days.

Cited by 68 publications

References 28 publications

Cardiac output changes after osmotic therapy in neurosurgical and neurocritical care patients: a systematic review of the clinical literature

Cardiac output changes after osmotic therapy in neurosurgical and neurocritical care patients: a systematic review of the clinical literature

Comparison of Hypertonic Saline and Mannitol on Whole Blood Coagulation In Vitro Assessed by Thromboelastometry

The effect of mannitol on intraoperative brain relaxation in patients undergoing supratentorial tumor surgery: study protocol for a randomized controlled trial

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