Mannitol versus hypertonic saline for brain relaxation in patients undergoing craniotomy

Prabhakar, Hemanshu; Singh, Gyaninder Pal; Anand, Vidhu; Kalaivani, Mani

doi:10.1002/14651858.cd010026.pub2

Cited by 19 publications

(8 citation statements)

References 17 publications

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“…Recent guidelines suggest the use of HTS as a second-line therapy in cases where mannitol fails to reduce ICP [8]. Despite hyperosmolar solutions being routinely used in neurosurgical and neurocritical care (NCC) patients for brain relaxation and ICP management [8][9][10][11][12][13][14], there is scanty information on the time course of their haemodynamic effects.…”

Section: Introductionmentioning

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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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: Introductionmentioning

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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“…The first reviewed the use of mannitol or HTS for brain relaxation in patients undergoing craniotomy for elective tumour resection. 12 It included six RCTs with 527 participants, and concluded that HTS significantly reduces the risk of tense brain during craniotomy (relative risk: 0.60; 95% CI: 0.44e0.83). Although not directly comparable to reviews of TBI, it does support the findings of Kamel and colleagues and Mortazavi and colleagues that HTS lowers ICP to a greater degree than mannitol.…”

Section: Pharmacology and Physiology Of Mannitol And Htsmentioning

confidence: 99%

Osmotherapy: science and evidence-based practice

Freeman

Welbourne

2018

BJA Education

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Osmotherapy can reduce intracranial pressure after traumatic brain injury. Mannitol and hypertonic saline have distinct actions and adverse effects. There is currently no evidence to support the overall superiority of one agent. It is unknown whether osmotherapy improves neurological outcome or mortality in traumatic brain injury. To ensure safety, any local guidelines should account for the different formulations available.

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“…Although there was no consensus on the best HS concentration for ICH control, in this study the 3% concentration was used because it was equiosmolar to 20% mannitol. In addition, it has shown good efficacy in intraoperative brain relaxation and in controlling ICH of various causes, with good safety and few side effects 39 , 40 , 41 .…”

Section: Discussionmentioning

confidence: 99%

Evaluation of cerebral hemodynamics by transcranial Doppler ultrasonography and its correlation with intracranial pressure in an animal model of intracranial hypertension

Soares

Andrade

Brasil

et al. 2022

Arq. Neuro-Psiquiatr.

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Background: Transcranial Doppler has been tested in the evaluation of cerebral hemodynamics as a non-invasive assessment of intracranial pressure (ICP), but there is controversy in the literature about its actual benefit and usefulness in this situation. Objective: To investigate cerebral blood flow assessed by Doppler technique and correlate with the variations of the ICP in the acute phase of intracranial hypertension in an animal model. Methods: An experimental animal model of intracranial hypertension was used. The experiment consisted of two groups of animals in which intracranial balloons were implanted and inflated with 4 mL (A) and 7 mL (B) for controlled simulation of different volumes of hematoma. The values of ICP and Doppler parameters (systolic [FVs], diastolic [FVd], and mean [FVm] cerebral blood flow velocities and pulsatility index [PI]) were collected during the entire procedure (before and during hematoma simulations and venous hypertonic saline infusion intervention). Comparisons between Doppler parameters and ICP monitoring were performed. Results: Twenty pigs were studied, 10 in group A and 10 in group B. A significant correlation between PI and ICP was obtained, especially shortly after abrupt elevation of ICP. There was no correlation between ICP and FVs, FVd or FVm separately. There was also no significant change in ICP after intravenous infusion of hypertonic saline solution. Conclusions: These results demonstrate the potential of PI as a parameter for the evaluation of patients with suspected ICP elevation.

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Mannitol versus hypertonic saline for brain relaxation in patients undergoing craniotomy

Abstract: Mannitol versus hypertonic saline for brain relaxation in patients undergoing craniotomy.

Cited by 19 publications

References 17 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

Osmotherapy: science and evidence-based practice

Evaluation of cerebral hemodynamics by transcranial Doppler ultrasonography and its correlation with intracranial pressure in an animal model of intracranial hypertension

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