Comparison of 20% mannitol and 7.5% hypertonic saline for supratentorial craniotomy

Demneri, M.; Hoxha, Ariela; Pilika, K.; Saraçi, M.

doi:10.1097/00003643-201106001-00340

Cited by 4 publications

(6 citation statements)

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“…Two RCTs proved the benefit of HTS over mannitol in terms of brain relaxation in patients undergoing supratentorial craniotomy. 153 , 154 However, the ICU days and hospital days were similar in both groups in one of these studies, 153 and the long-term neurological outcomes were not studied in either trial. 153 , 154 A meta-analysis and systemic review from TBI reported better control of elevated ICP with the use of HTS compared with mannitol.…”

Section: Anesthetic Management Of Surgical Clippingmentioning

confidence: 93%

Aneurysmal Subarachnoid Hemorrhage

D’Souza

2015

Journal of Neurosurgical Anesthesiology

232

145

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Aneurysmal subarachnoid hemorrhage (SAH) is a worldwide health burden with high fatality and permanent disability rates. The overall prognosis depends on the volume of the initial bleed, rebleeding, and degree of delayed cerebral ischemia (DCI). Cardiac manifestations and neurogenic pulmonary edema indicate the severity of SAH. The International Subarachnoid Aneurysm Trial (ISAT) reported a favorable neurological outcome with the endovascular coiling procedure compared with surgical clipping at the end of 1 year. The ISAT trial recruits were primarily neurologically good grade patients with smaller anterior circulation aneurysms, and therefore the results cannot be reliably extrapolated to larger aneurysms, posterior circulation aneurysms, patients presenting with complex aneurysm morphology, and poor neurological grades. The role of hypothermia is not proven to be neuroprotective according to a large randomized controlled trial, Intraoperative Hypothermia for Aneurysms Surgery Trial (IHAST II), which recruited patients with good neurological grades. Patients in this trial were subjected to slow cooling and inadequate cooling time and were rewarmed rapidly. This methodology would have reduced the beneficial effects of hypothermia. Adenosine is found to be beneficial for transient induced hypotension in 2 retrospective analyses, without increasing the risk for cardiac and neurological morbidity. The neurological benefit of pharmacological neuroprotection and neuromonitoring is not proven in patients undergoing clipping of aneurysms. DCI is an important cause of morbidity and mortality following SAH, and the pathophysiology is likely multifactorial and not yet understood. At present, oral nimodipine has an established role in the management of DCI, along with maintenance of euvolemia and induced hypertension. Following SAH, hypernatremia, although less common than hyponatremia, is a predictor of poor neurological outcome.

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Section: Anesthetic Management Of Surgical Clippingmentioning

confidence: 93%

Aneurysmal Subarachnoid Hemorrhage

D’Souza

2015

Journal of Neurosurgical Anesthesiology

232

145

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“…Three studies enrolling 387 participants reported brain relaxation (73.4% of total participants in this review). [13,15,16] These three trials suggest that the incidence of inadequate brain relaxation was reduced from 68 of 190 in the mannitol group to 42 of 197 in the hypertonic saline group (RR of brain bulge 0.60, 95% CI -0.44-0.83, P -0.002). No heterogeneity was noted in these studies [ Figure 4].…”

Section: Secondary Outcomes Brain Relaxationmentioning

confidence: 93%

“…We included six studies in our review [ Figure 1]. [4,5,[13][14][15][16] All included studies were of parallel design, and only three studies [13][14][15][16] used equiosmolar concentrations of fluids. None of the included studies reported our primary outcomes.…”

Section: Included Studiesmentioning

confidence: 99%

“…Five studies reported data on all participants. [4,5,[14][15][16] However, this information remained unclear in one study [13] as it was presented as an abstract and study authors failed to include it.…”

Section: Incomplete Outcome Data (Attrition Bias)mentioning

confidence: 99%

“…The source of the intervention fluid remained unclear in another study. [13] Effects of interventions…”

Section: Other Potential Sources Of Biasmentioning

confidence: 99%

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Mannitol versus hypertonic saline for brain relaxation in patients undergoing craniotomy – A Cochrane Systematic Review

Prabhakar

Singh

Kalaivani

et al. 2017

Journal of Neuroanaesthesiology and Critical Care

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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. The objective of this review was to compare the effects of mannitol versus those of hypertonic saline on intraoperative brain relaxation in patients undergoing craniotomy. Methods: We searched the Cochrane Central Register of Controlled Trials (2013, Issue 10), MEDLINE through OvidSP (1966 to October 2013) and EMBASE through OvidSP (1980 to October 2013). We also searched specific websites, such as www.indmed.nic.in, www.cochrane-sadcct.org and www.clinicaltrials.gov. We included randomised 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. The primary outcomes were longest follow-up mortality, Glasgow outcome scale score at 3 months and any adverse event related to mannitol or hypertonic saline. The secondary outcomes were intraoperative brain relaxation, Intensive Care Unit (ICU) stay, hospital stay and quality of life. We used standardised 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. 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 3 months or any adverse event related to mannitol or hypertonic saline. Three trials mentioned that the secondary outcomes of intraoperative brain relaxation, hospital stay, ICU stay and quality of life were not reported in any of the trials. Brain relaxation was inadequate in 42 of 197 participants in the hypertonic saline group and 68 of 190 participants in the mannitol group. The risk ratio for brain bulge or tense brain in the hypertonic saline group was 0.60 (95% confidence interval 0.44–0.83, low-quality evidence). One trial reported ICU and hospital stay. The mean (standard deviation [SD]) duration of ICU stay in the mannitol and hypertonic saline groups was 1.28 (0.5) and 1.25 (0.5) days (P - 0.64), respectively; the mean (SD) duration of hospital stay in the mannitol and hypertonic saline groups was 5.7 (0.7) and 5.7 (0.8) days (P - 1.00), respectively. Conclusions: From the limited data available on the use of mannitol and hypertonic saline for brain relaxation during craniotomy, it is suggested that hypertonic saline significantly reduces the risk of tense brain during craniotomy. A single trial suggests that ICU stay and hospital stay are comparable with the use of mannitol or hypertonic saline. However, focus on other related important issues such as long-term mortality, long-term outcome, adverse events and quality of life is needed.

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