Hypertonic Saline Versus Mannitol for Increased Intracranial Pressure Management

1. Hypertonic Saline
Mannitol
Ade Wijaya, MD
May 2018

2. Introduction
• Mannitol as 1st line osmotic agent for decreasing ICP in:
1. Intracerebral hemorrhage
2. Traumatic brain injury
3. Malignant cerebral infarction
4. Subarachnoid hemorrhage
5. Acute liver failure
Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, et al: Guidelines for the management of severe traumatic brain injury. II. Hyperosmolar therapy. J Neurotrauma 2007; 24:S14 –S20
Broderick J, Connolly S, Feldmann E, et al: Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: A guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research
Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Circulation 2007; 116: e391– e413
Adams HP Jr, del Zoppo G, Alberts MJ, et al: Guidelines for the early management of Figure Forest plot showing difference in mean quantitative reduction of intracranial pressure (mm Hg). WMD, weighted mean difference; CI, confidence interval. Crit Care Med 2011
Vol. 39, No. 3 557 adults with ischemic stroke: A guideline from the American Heart Association/ American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular
Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007; 38:1655–1711
Bederson JB, Connolly ES Jr, Batjer HH, et al: Guidelines for the management of aneurysmal subarachnoid hemorrhage: A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 2009; 40:994 –1025
Stravitz RT, Kramer AH, Davern T, et al: Intensive care of patients with acute liver failure: Recommendations of the U.S. Acute Liver Failure Study Group. Crit Care Med 2007; 35:2498 –2508

3. Introduction
• Mannitol adverse effects: renal failure and hypovolemia
• Hypertonic saline formulations, which can reduce ICP without causing
volume contraction and with less risk of nephrotoxicity
Kamel H, Navi BB, Nakagawa K, Hemphill JC, Ko NU. Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Critical care medicine. 2011 Mar 1;39(3):554-9.

4. Harary, M.; Dolmans, R.G.F.; Gormley, W.B. Intracranial Pressure Monitoring—Review and Avenues for Development. Sensors 2018, 18, 465.

5. Guidelines for the Management of Severe Traumatic Brain Injury. Journal of Neurotrauma. 2007, Vol. 24, Supp 1): S1-S106.
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults, 2007 Update. Stroke. 2007 Jun;38(6):2001-2003.

7. Mannitol
• (0,25-0,5 g / kg IV) within 20 minutes every 6 hours
• Maximum daily dose : 2 g / kg

10. Summary from recent metaanalysis
• Hypertonic saline is more effective than mannitol for the treatment of
intracranial hypertension.