Comparison of 20% mannitol and 3% hypertonic saline on intracranial pressure and systemic hemodynamics

Sokhal, Navdeep; Rath, Girija Prasad; Chaturvedi, Arvind; Singh, Manmohan; Dash, Hari H.

doi:10.1016/j.jocn.2017.03.016

Cited by 35 publications

(55 citation statements)

References 30 publications

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“…The full-text evaluation identified 18 studies as not appropriate, no full-text publication and non-observational or RCT studies, and were finally excluded. The selected eight articles consisted of four RCTs [19][20][21][22] and three prospective [23][24][25] and 1 retrospective [26] observational studies, that enrolled a total of 182 adult patients. All these studies met the criteria to be included in the final qualitative appraisal, Table 1 Physiological and clinical effects of mannitol vs. hypertonic saline …”

Section: Study Selectionmentioning

confidence: 99%

“…Five studies were conducted in elective craniotomy setting [20][21][22][23]26], while the remaining three enrolled NCC patients treated either for subarachnoid haemorrhage [9] or traumatic brain injury [24,25]. Three studies included the administration of either mannitol [23,25] or HTS [24] as a sole osmotherapy; four trials (two observational and two RCTs) compared mannitol with HTS [combined or not to hydroxyethyl starch (HES)] [20][21][22]24], and in one RCT, the haemodynamic effects of mixed HTS-HES solution were tested against placebo [19].…”

Section: Description Of Included Trialsmentioning

confidence: 99%

“…Three studies included the administration of either mannitol [23,25] or HTS [24] as a sole osmotherapy; four trials (two observational and two RCTs) compared mannitol with HTS [combined or not to hydroxyethyl starch (HES)] [20][21][22]24], and in one RCT, the haemodynamic effects of mixed HTS-HES solution were tested against placebo [19]. Haemodynamic effects of mannitol were recorded as primary outcome end-point in two of the included studies [23,24].…”

Section: Description Of Included Trialsmentioning

confidence: 99%

“…A considerable variability was recorded in the timing of osmotic agents administration. As for the subgroup of patients subjected to craniotomy surgery, this was defined as 15 min before dura opening [23,25], 30 min before skull opening [21], during scalp incision [20] or shortly afterwards the drilling for the first burr hole of craniotomy was performed [22].…”

Section: Description Of Included Trialsmentioning

confidence: 99%

“…The cut-off ICP values defined as a criterion for osmotherapy application in NCC patients ranged from 15 mmHg [23] to 20 mmHg [26], whereas ethical issues in a placebo-controlled RCT dictated the administration of an osmotic agent for ICP values <20 mmHg [19]. Moreover, a notable discrepancy in the follow-up period was recorded ranging from 45 min [21,22,26] to 6 h [20]. The most common tool for continuous non-invasive estimation of CO was based on pulse contour analysis, which was applied in four studies [19][20][21][22], whereas transthoracic electrical bioimpedance and transoesophageal echocardiography were used alternatively in two other studies [23,25].…”

Section: Description Of Included Trialsmentioning

confidence: 99%

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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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