Critical Care Pharmacist with special interests in trauma and surgery.
Aspiring Medical Student and current Critical Care RN. Enjoys everything outdoors but can also be found inside nerding out on her medical education artwork
The Pre-brief
A 50-year-old man presents as a pedestrian struck with polytrauma, including severe TBI. Upon arrival to the resuscitation bay, the patient is noted to have a right-sided blown pupil, concerning for herniation. Which hypertonic solution should be administered: HTS or mannitol?
What does the literature say?
A full literature review remains outside the scope of this article, however, two recent studies re-evaluated HTS vs mannitol and their effects on ICP.
*Additional resources and references are cited at the end of this article*
What did they find?
Here is a summary analysis of the first paper:
And here is the summary analysis of the second paper:
The Debrief
Both HTS and mannitol are effective in decreasing ICP; however, one must consider the patient presentation. HTS is an effective volume expander while mannitol is an osmotic diuretic, thus, HTS should be preferred if there are needs for resuscitation. However, because elevated ICP is considered a neurologic emergency, whichever agent is readily available should be administered. Serial sodium monitoring should be performed with HTS therapy as rapid changes in serum concentrations may lead to osmotic demyelination syndrome. Patients on prolonged mannitol therapy are at risk of acute kidney injury – be sure to measure serum osmolality gaps.
Reference
- Emergency Neurological Life Support Intracranial Hypertension and Herniation Protocol. Neurocritical Care Society. March 2020
- Shi J,et al. Hypertonic saline and mannitol in patients with traumatic brain injury: a systematic and meta-analysis. Medicine 2020;99:35.
- Mangat HS, et al. Hypertonic Saline is Superior to Mannitol for the Combined Effect on Intracranial Pressure and Cerebral Perfusion Pressure Burdens in Patients With Severe Traumatic Brain Injury. Neurosurgery. 2020 Feb 1;86(2):221-230.
- Burgess S, Abu-Laban RB, Slavik RS, Vu EN, Zed PJ. A Systematic Review of Randomized Controlled Trials Comparing Hypertonic Sodium Solutions and Mannitol for Traumatic Brain Injury: Implications for Emergency Department Management. Ann Pharmacother. 2016 Apr;50(4):291-300.
- Chen H, Song Z, Dennis JA. Hypertonic saline versus other intracranial pressure-lowering agents for people with acute traumatic brain injury. Cochrane Database Syst Rev. 2019 Dec 30;12(12):CD010904.
- García-Morales EJ, et al. Osmole gap in neurologic-neurosurgical intensive care unit: Its normal value, calculation, and relationship with mannitol serum concentrations. Crit Care Med. 2004 Apr;32(4):986-91.
