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. 2013 Aug 5;2013(8):CD001049.
doi: 10.1002/14651858.CD001049.pub5.

Mannitol for acute traumatic brain injury

Abel Wakai  1 , Aileen McCabe, Ian Roberts, Gillian Schierhout
Affiliations

Mannitol for acute traumatic brain injury

Abel Wakai et al. Cochrane Database Syst Rev. .

Abstract

Background: Mannitol is sometimes effective in reversing acute brain swelling, but its effectiveness in the ongoing management of severe head injury remains unclear. There is evidence that, in prolonged dosage, mannitol may pass from the blood into the brain, where it might cause increased intracranial pressure.

Objectives: To assess the effects of different mannitol therapy regimens, of mannitol compared to other intracranial pressure (ICP) lowering agents, and to quantify the effectiveness of mannitol administration given at other stages following acute traumatic brain injury.

Search methods: We searched the Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library), MEDLINE (OvidSP), EMBASE (OvidSP), ISI Web of Science (SCI-EXPANDED & CPCI-S) and PubMed. We checked reference lists of trials and review articles, and contacted authors of trials. The search was updated on the 20th April 2009.

Selection criteria: Randomised controlled trials of mannitol, in patients with acute traumatic brain injury of any severity. The comparison group could be placebo-controlled, no drug, different dose, or different drug. We excluded cross-over trials, and trials where the intervention was started more than eight weeks after injury.

Data collection and analysis: We independently rated quality of allocation concealment and extracted the data. Relative risks (RR) and 95% confidence intervals (CI) were calculated for each trial on an intention to treat basis.

Main results: We identified four eligible randomised controlled trials. One trial compared ICP-directed therapy to 'standard care' (RR for death = 0.83; 95% CI 0.47 to 1.46). One trial compared mannitol to pentobarbital (RR for death = 0.85; 95% CI 0.52 to 1.38). One trial compared mannitol to hypertonic saline (RR for death = 1.25; 95% CI 0.47 to 3.33). One trial tested the effectiveness of pre-hospital administration of mannitol against placebo (RR for death = 1.75; 95% CI 0.48 to 6.38).

Authors' conclusions: Mannitol therapy for raised ICP may have a beneficial effect on mortality when compared to pentobarbital treatment, but may have a detrimental effect on mortality when compared to hypertonic saline. ICP-directed treatment shows a small beneficial effect compared to treatment directed by neurological signs and physiological indicators. There are insufficient data on the effectiveness of pre-hospital administration of mannitol.

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Conflict of interest statement

None known.

Figures

1
1
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies. Four studies are included in this review.
1.1
1.1. Analysis
Comparison 1 ICP‐directed mannitol ('treatment') compared to mannitol according to neurological signs ('control'), Outcome 1 Death.
1.2
1.2. Analysis
Comparison 1 ICP‐directed mannitol ('treatment') compared to mannitol according to neurological signs ('control'), Outcome 2 Death or severe disability.
2.1
2.1. Analysis
Comparison 2 Mannitol versus pentobarbital, Outcome 1 Death.
3.1
3.1. Analysis
Comparison 3 Mannitol versus hypertonic saline, Outcome 1 Death.
4.1
4.1. Analysis
Comparison 4 Mannitol versus placebo, Outcome 1 Death.
See this image and copyright information in PMC

Update of

Comment in

References

References to studies included in this review

Sayre 1996 {published data only}
    1. Sayre MR, Daily SW, Stern SA, Storer DL, Loveren HR, Hurst JD. Out‐of‐hospital administration of mannitol does not change systolic blood pressure. Academic Emergency Medicine 1996;3(9):840‐8. [MEDLINE: ] - PubMed
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References to studies excluded from this review

Battison 2005 {published data only}
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Harutjunyan 2005 {published data only}
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Ichai 2009 {published data only}
    1. Ichai C, Armando G, Orban J‐C, Berthier F, Rami L, Samat‐Long C, et al. Sodium lactate versus mannitol in the treatment of intracranial hypertensive episodes in severe traumatic brain‐injured patients. Intensive Care Medicine 2009;35:471‐479. - PubMed
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    1. Midgley S. CPP and SJO2 with ICP Reduction Therapy After Severe Head Injury. Intracranial Pressure. New York: Springer‐Verlag, 1993:558‐63.
Smedema 1993 {published data only}
    1. Smedema RJA. Comparison Study Between Mannitol and Glycerol Therapy in Reducing Intracranial Pressure. Intracranial Pressure. Vol. 8, New York: Springer‐Verlag, 1993:605‐8.

Additional references

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