Summary
The response to intravenous bolus administrations and continuous infusions of hypertonic mannitol to control elevated (> 25 torr) intracranial pressure (ICP) is presented. Sixty patients received 120 bolus infusions of mannitol (0.18–2.5 g/kg/ dose) with a prompt peak reduction at 44 minutes (range 18 to 120 minutes). There was no relationship between dosage and rapidity of peak response. All administrations of 1.0 g/kg/dose, or higher, consistently reduced ICP 10% or more from control values, but dosages below 1 gm/kg/dose did not always reduce ICP. Return to control ICP following mannitol was unpredictable, and was related to the initial ICP and the volume of fluid replacement. A continuous infusion of mannitol was administered to maintain ICP below 25 torr in 18 patients. This infusion ranged from 6 to 100 hours (×28.8±28.9 hours) and required a total dosage of 2–20 mg/kg, and was successful in 16 of the 18 patients. Emphasis is placed on close observation of the patient's serum osmolality and electrolytes during therapy, as well as quality and magnitude of replacement. No set rules are given for control of ICP, but a guideline is made to meet the individual patient's requirements.
Similar content being viewed by others
References
Aviram, A., Pfan, A., Czaczkes, J. W., Ulman, J. D., Hyperosmolality with hyponatremia caused by inappropriate administration of mannitol. Amer. J. Med.42 (1967), 648–650.
Bakay, L., Crawford, J. D., White, J. C., The effects of intravenous fluids on cerebrospinal fluid pressure. Surg. Gynec.99 (1954), 48–52.
Becker, D. P., Vries, J. K., The alleviation of increased intracranial pressure by the chronic administration of osmotic agents. In: ICP, pp. 310–315 (Brock, M., Dietz, H., eds.). Berlin-Heidelberg-New York: Springer. 1972.
Becker, D. P., Vries, J. K., Young, H. F., Ward, J. D., Controlled cerebral perfusion pressure and ventilation in human mechanical injury: prevention of progressive brain swelling. In: ICP II, pp. 480–484 (Lundberg, N., Ponten, E., Brock, M., eds.). Berlin-Heidelberg-New York: Springer. 1975.
Beks, J. W. F., Groen, A., Huizinga, T., Noordhoek, K. H. N., Smit, J. M., Walter, W. G., Effects of intravenously administered hypertonic urea solution. Acta Neurochir. (Wien)13 (1965), 1–10.
Beks, J., ter Weeme, C., The influence of urea and mannitol on increased intraventricular pressure in cold-induced cerebral edema. Acta Neurochir. (Wien)16 (1967), 97–107.
Bruce, D. A., Langfitt, T. W., Miller, J. D., Schutz, H., Vapalahti, M. P., Stanek, A., Goldberg, H. I., Regional cerebral blood flow, intracranial pressure, and brain metabolism in comatose patients. J. Neurosurg.38 (1973), 131–144.
Bullock, L. T., Gregersen, M. I., Kinney, R., The use of hypertonic sucrose solution intravenously to reduce cerebrospinal fluid pressure without a secondary rise. Amer. J. Physiol.112 (1935), 82–96.
Clasen, R., Cooke, P., Pandolfi, S., Carnecki, G., Bryan, G., Hypertonic urea in experimental cerebral edema. Arch. Neurol. (Chicago)12 (1965), 424–434.
Clasen, R. A., Prouty, R. R., Bingham, W. G., Martin, F. A., Hass, G. M., Treatment of experimental cerebral edema with intravenous hypertonic glucose, albumin, and dextran. Surg. Gynec. Obstet.104 (1957), 591–606.
Collice, M., Rossanda, M., Bedusehi, A., Porta, M., Management of head injury by means of ventricular fluid pressure monitoring. In: ICP III, pp. 101–109 (Beks, J. W. F., Bosch, D. A., Brock, M., eds.). Berlin-Heidelberg-New York: Springer. 1976.
Einspruch, B., Clark, K., Further studies on the effectiveness of agents used to lower intracranial pressure. J. Neurosurg.23 (1965), 45–48.
Fishman, R. A., Effects of isotonic intravenous solutions on normal and increased intracranial pressure. Arch. Neurol. Psychiat.70 (1953), 350–360.
Fremont-Smith, F., Forbes, H. S., Intra-ocular and intracranial pressure: an experimental study. Arch. Neurol. Psychiat.18 (1927), 550–564.
Goluboff, B., Shenkin, H., Hoft, H., The effects of mannitol and urea on cerebral hemodynamics and cerebrospinal fluid pressure. Neurology (Minneap.)14 (1964), 891–898.
Irvine, M. D., Administration of urea for reduction of intracranial and intraocular pressure. Amer. J. Ophthal.49 (1960), 164–166.
Jaird, M., Andersen, J., The effect of urea on cerebrospinal fluid pressure in monkeys before and after bilateral nephrectomy. J. Lab. Clin. Med.53 (1959), 484–489.
James, H. E., Analysis of therapeutic modalities for head injured children. Child's Brain5 (1979), 263–271.
James, H. E., Bruce, D. A., Welsh, F., Cytotoxic edema produced by 6-aminonicotinamide and its response to therapy. Neurosurgery3 (1978), 196–200.
James, H. E., Bruno, L., Shapiro, H. M., Levitt, J. D., Aidinis, S., Langfitt, T. W., Methodology for intraventricular and subarachnoid continuous recording of intracranial pressure in clinical practice. Acta Neurochir. (Wien)33 (1976), 45–51.
James, H. E., Harbaugh, R. D., Marshall, L. F., Shapiro, H. M., Laurin, R., Multiple therapeutic modalities in experimental vasogenic edema. In press.
James, H. E., Langfitt, T. W., Kumar, V. S., Ghostine, S. Y., Treatment of intracranial hypertension: Analysis of 105 consecutive, continuous recordings of intracranial pressure. Acta Neurochir. (Wien)36 (1977), 189–200.
James, H. E., Langfitt, T. W., Kumar, V. S., Analysis of the response to therapeutic measures to reduce intracranial pressure in head injured patients. J. Trauma16 (1976), 437–441.
Javid, M., Gilboe, D., Cesario, T., The rebound phenomenon and hypertonic solutions. J. Neurosurg. (1964), 1059–1066.
Johnston, I. H., Harper, A. M., The effect of mannitol on cerebral blood flow: An experimental study. J. Neurosurg.36 (1973), 461–471.
Johnston, I. H., Paterson, A., Harper, A. M., Jennett, W. B., The effect of mannitol on intracranial pressure and cerebral blood flow. In: ICP, pp. 176–180 (Brock, M., Dietz, H., eds.). Berlin-Heidelberg-New York: Springer. 1972.
Kullberg, G., Sundbarg, G., Reduction of raised intracranial pressure following infusion of mannitol. In: ICP III, pp. 224–227 (Beks, J. W. F., Bosch, D. A., Brock, M., eds.). Berlin-Heidelberg-New York: Springer. 1976.
Langfitt, T. W., Possible mechanisms of action of hypertonic urea in reducing intracranial pressure. Neurol.11 (1961), 196–209.
Leech, P., Miller, J. D., Intracranial volume-pressure relationships during experimental brain compression in primates. 3. Effects of mannitol and hyperventilation. J. Neurol. Neurosurg. Psychiatry37 (1974), 1105–1111.
Marshall, L. F., Smith, R. W., Rauscher, L. A., Shapiro, H. M., Mannitol dose requirements in brain-injured patients. J. Neurosurg.48 (1978), 169–172.
Masserman, J. H., Effects of intravenous administration of hypertonic solutions of dextrose. With special reference to the cerebrospinal fluid pressure. J. A. M. A.102 (1934), 2084–2086.
McQueen, J. D., Jeanes, L. D., Dehydration and rehydration of the brain with hypertonic urea and mannitol. J. Neurosurg.21 (1964), 118–128.
Miller, J. D., Leech, P., Effects of mannitol and steroid therapy on intracranial volume-pressure relationships in patients. J. Neurosurg.42 (1975), 274–281.
Pappius, H. M., Dayes, L. A., Hypertonic urea: Its effect on the distribution of water and electrolytes in normal and edematous brain tissue. Arch. Neurol.13 (1965), 395–402.
Prill, A., Volles, E., Dahlman, W., Stabilization and disturbance of csmoregulation in the cerebrospinal fluid. In: ICP, pp. 303–308 (Brock, M., Dietz, H., eds.). Berlin-Heidelberg-New York: Springer. 1972.
Reed, D., Woodbury, D., Effect of urea and acetazolamide on brain volume and cerebrospinal fluid pressure. J. Physiol.164 (1962), 265–273.
Reed, D. J., Woodbury, D. M., Effect of hypertonic urea on cerebrospinal fluid pressure and brain volume. J. Physiol.164 (1962), 252–264.
Scewczykowski, J., Slivka, S., Kunicki, A., Korsack-Slivka, J., Dziduszko, J., Dytko, P., Augustyniak, B., Computer-assisted analysis of intraventricular pressure after mannitol administration. J. Neurosurg.43 (1975), 136–141.
Shenkin, H. A., Bezier, H. S., Bouzarth, W. F., Restricted fluid intake. J. Neurosurg.45 (1976), 432–436.
Shenkin, H. A., Goluboff, B., Haft, H., The use of mannitol for the reduction of intracranial pressure in intracranial surgery. J. Neurosurg.19 (1962), 897–901.
Silber, S. J., Thompson, N., Mannitol-induced central nervous system toxicity in renal failure. Invest. Urol.9 (1972), 310–312.
Sotos, J. F., Dodge, P. R., Meara, P., Talbot, N. B., Studies in experimental hypertonicity. Peds.26 (1960), 925–928.
Stuart, F. P., Torres, E., Fletcher, D., Moore, F. D., Effects of repeated and massive mannitol infusion in the dog. Structural and functional changes in kidney and brain. Amer. Surg.172 (1970), 190–204.
Troupp, H., Valtonen, S., Vapalahti, M., Intraventricular pressure after administration of dehydrating agents to severely brain injured patients: Is there a rebound phenomenon? Acta Neurochir. (Wien)24 (1971), 89–95.
Weed, L. H., McKibben, P. S., Pressure changes in the cerebrospinal fluid following intravenous injection of solutions of various concentrations. Amer. J. Physiol.48 (1919), 512–530.
Wise, B. L., Effects of infusion of hypertonic mannitol on electrolyte balance and on osmolarity of serum and cerebrospinal fluid. J. Neurosurg.20 (1963), 961–967.
Wise, B. L., Chater, N., The value of hypertonic mannitol solution in decreasing brain mass and lowering cerebrospinal fluid pressure. J. Neurosurg.19 (1962), 1038–1043.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
James, H.E. Methodology for the control of intracranial pressure with hypertonic mannitol. Acta neurochir 51, 161–172 (1980). https://doi.org/10.1007/BF01406742
Issue Date:
DOI: https://doi.org/10.1007/BF01406742