Mannitol dose requirements in brain-injured patients

Marshall, Lawrence F.; Smith, Randall W.; Rauscher, L A; Shapiro, Harvey M.

doi:10.3171/jns.1978.48.2.0169

Cited by 229 publications

(64 citation statements)

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“…10,11,29,35 Mannitol reduces ICP and mortality rates after head injury and is superior to pentobarbital in reducing the occurrence and severity of ICP elevations. 30,45,47 However, hypertonic saline (HTS) has increasing pilot data supporting its efficacy. 1,17,20,21,25,48,51 Recent meta-analyses of observational studies comparing mannitol and HTS in the treatment of raised ICP support HTS as a superior agent for lowering ICP.…”

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confidence: 99%

Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury

Mangat

Chiu²,

Gerber

et al. 2015

JNS

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ObJect Increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI) is associated with a higher mortality rate and poor outcome. Mannitol and hypertonic saline (HTS) have both been used to treat high ICP, but it is unclear which one is more effective. Here, the authors compare the effect of mannitol versus HTS on lowering the cumulative and daily ICP burdens after severe TBI. MetHODS The Brain Trauma Foundation TBI-trac New York State database was used for this retrospective study. Patients with severe TBI and intracranial hypertension who received only 1 type of hyperosmotic agent, mannitol or HTS, were included. Patients in the 2 groups were individually matched for Glasgow Coma Scale score (GCS), pupillary reactivity, craniotomy, occurrence of hypotension on Day 1, and the day of ICP monitor insertion. Patients with missing or erroneous data were excluded. Cumulative and daily ICP burdens were used as primary outcome measures. The cumulative ICP burden was defined as the total number of days with an ICP of > 25 mm Hg, expressed as a percentage of the total number of days of ICP monitoring. The daily ICP burden was calculated as the mean daily duration of an ICP of > 25 mm Hg, expressed as the number of hours per day. The numbers of intensive care unit (ICU) days, numbers of days with ICP monitoring, and 2-week mortality rates were also compared between the groups. A 2-sample t-test or chisquare test was used to compare independent samples. The Wilcoxon signed-rank or Cochran-Mantel-Haenszel test was used for comparing matched samples. reSultS A total of 35 patients who received only HTS and 477 who received only mannitol after severe TBI were identified. Eight patients in the HTS group were excluded because of erroneous or missing data, and 2 other patients did not have matches in the mannitol group. The remaining 25 patients were matched 1:1. Twenty-four patients received 3% HTS, and 1 received 23.4% HTS as bolus therapy. All 25 patients in the mannitol group received 20% mannitol. The mean cumulative ICP burden (15.52% [HTS] vs 36.5% [mannitol]; p = 0.003) and the mean (± SD) daily ICP burden (0.3 ± 0.6 hours/day [HTS] vs 1.3 ± 1.3 hours/day [mannitol]; p = 0.001) were significantly lower in the HTS group. The mean (± SD) number of ICU days was significantly lower in the HTS group than in the mannitol group (8.5 ± 2.1 vs 9.8 ± 0.6, respectively; p = 0.004), whereas there was no difference in the numbers of days of ICP monitoring (p = 0.09). There were no significant differences between the cumulative median doses of HTS and mannitol (p = 0.19). The 2-week mortality rate was lower in the HTS group, but the difference was not statistically significant (p = 0.56). cONcluSiONS HTS given as bolus therapy was more effective than mannitol in lowering the cumulative and daily ICP burdens after severe TBI. Patients in the HTS group had significantly lower number of ICU days. The 2-week mortality rates were not statistically different between the 2 groups.http://thejns.org/doi/abs/10.3171/2014....

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Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury

Mangat

Chiu²,

Gerber

et al. 2015

JNS

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“…Also, Marshall et al have suggested that a mannitol bolus of 0.25g/kg reduces ICP as much as larger doses of mannitol. 27 Based on the results reported by Marshall et al and those of the present study, a mannitol bolus of 0.25 g/kg is allowable a maximum of 6 times per day. This management is used in clinical practice.…”

Section: Discussionmentioning

confidence: 99%

Increased risk of acute kidney injury associated with higher infusion rate of mannitol in patients with intracranial hemorrhage

Kim

Park²,

Kang

et al. 2014

JNS

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Object. Mannitol, an osmotic agent used to decrease intracranial pressure, can cause acute kidney injury (AKI). The objectives of this study were to assess the impact of mannitol on the incidence and severity of AKI and to identify risk factors and outcome for AKI in patients with intracranial hemorrhage (ICH).Methods. The authors retrospectively evaluated 153 adult patients who received mannitol infusion after ICH between January 2005 and December 2009 in the neurosurgical intensive care unit. Multivariate analysis was used to evaluate the risk factors for AKI after ICH. Based on the odds ratio, weighted scores were assigned to predictors of AKI.Results. The overall incidence of AKI among study participants was 10.5% (n = 16). Acute kidney injury occurred more frequently in patients who received mannitol infusion at a rate ≥ 1.34 g/kg/day than it did in patients who received mannitol infusion at a rate < 1.34 g/kg/day. A higher mannitol infusion rate was associated with more severe AKI. Independent risk factors for AKI were mannitol infusion rate ≥ 1.34 g/kg/day, age ≥ 70 years, diastolic blood pressure (DBP) ≥ 110 mm Hg, and glomerular filtration rate < 60 ml/min/1.73 m 2 . The authors developed a risk model for AKI, wherein patients with a higher risk score showed a graded association with a higher incidence of AKI.Conclusions. The incidence of AKI following mannitol infusion in patients with ICH was 10.5%. A higher mannitol infusion rate was associated with more frequent and more severe AKI. Additionally, age ≥ 70 years, DBP ≥ 110 mm Hg, and established renal dysfunction before starting mannitol therapy were associated with development of AKI. (http://thejns.org/doi/abs/10.3171/2013.12.JNS13888) KeY WorDs • acute kidney injury • intracranial hemorrhage • mannitol • vascular disordersAbbreviations used in this paper: AKI = acute kidney injury; AKIN = Acute Kidney Injury Network; AUC = area under the curve; DBP = diastolic blood pressure; GFR = glomerular filtration rate; ICH = intracranial hemorrhage; ICP = intracranial pressure; IQR = interquartile range; ROC = receiver operating characteristic; SBP = systolic blood pressure.

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“…If hyperventilation does not control the ICP, mannitol must be administered in a bolus at a dose of 0.25 g/kg. Administering it in infusion or at higher doses do not improve the result [135]. Osmolarity and intravascular volume status must be monitored, because hyperosmolarity or hypovolemia may occur and negatively affect the prognosis.…”

Section: Initial Neurologic Evaluation Of the Trauma Patientmentioning

confidence: 99%

Critical Care Issues in the Early Management of Severe Trauma

García

2006

Surgical Clinics of North America

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Violent trauma and road traffic injuries kill more than 2.5 million people in the world every year. It has been calculated by the World Health Organization that in 2002 there occurred 1.6 million violent deaths [1] and 1.2 million deaths from traffic injury [2], for a combined mortality of 48 deaths per 100,000 population per year.Most trauma deaths occur at the scene or in the first hour after trauma, with a proportion from 34% to 50% occurring in hospitals [3]. These deaths could be prevented by optimization of trauma care. Preventability of trauma deaths has been reported as high as 76% [4] and as low as 1% in mature trauma systems [5,6].Prehospitalization procedures, elapsed time to hospital arrival are, of course, vital to the whole trauma scenario, but errors made in the in-hospital phase of care are responsible for one third to two thirds of the reported by different authors [7,8]. Of these, intensive care unit (ICU) errors are among the most frequent and significant. Errors in the ICU management of trauma patients were studied by Duke and colleagues [9]. They reported 165 ICU trauma deaths. Two hundred fifty-eight errors occurred in 81 patients (52%), and 134 of them contributed to death in 52 patients (34%). ICU errors were classified as management errors (82%), diagnostic (9%), technique (5%), and system inadequacies (4%). Davis and colleagues [10] identified critical care errors in 30% of 125 trauma deaths with errors. These errors contributed to 48% of all preventable deaths.The most common critical care errors are related to airway and respiratory management, fluid resuscitation, neurotrauma diagnosis and support, and delayed diagnosis of critical lesions [9,10].It is imperative for the general surgeon who takes care of trauma patients to know how to deal with these critical aspects, to reduce preventable morbidity and mortality. In the next segment, the situations in which the participation of the surgeon is crucial, during the initial phases of reanimation and stabilization of the critically traumatized patient will be discussed. Airway and ventilation managementAirway and respiratory management errors are the most common of those identified by several authors [9][10][11] The cardinal manifestation is a sudden or a rapidly progressing desaturation, frequently accompanied by tachycardia and arrhytmias, and occasionally by agitation. Hypertension announces the cardiovascular collapse, and bradicardia appears immediately after the total collapse [12]. The symptoms should not be attributed to agitation when it is present, and other possible causes must be ruled out before. Diagnosing the complication involves a directed physical examination, the analysis of the airway pressures and ventilator volumes, chest radiographs, and sometimes the measurement of arterial blood gases (ABG), and the urinary bladder pressure ( Table 1).The emergency conditions in which the access to the airways must be gained, the displacement to diagnosis areas or operating room and the agitation, often present, make the critical...

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Mannitol dose requirements in brain-injured patients

Cited by 229 publications

References 6 publications

Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury

Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury

Increased risk of acute kidney injury associated with higher infusion rate of mannitol in patients with intracranial hemorrhage

Critical Care Issues in the Early Management of Severe Trauma

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