Hypertonic Saline Versus Mannitol for ICP Reduction

• Elevated intracranial pressure (ICP) is caused by excess volume in the cerebral spaces, which causes a

reduction in the cerebral perfusion pressure and affects blood flow and oxygenation to the brain.

• Hyperosmolar agents (hypertonic saline and mannitol) are utilized to form a gradient across the blood-brain

barrier to draw fluid from the cerebral space into the vasculature, thus reducing ICP

• Mannitol was previously considered the gold standard of osmotic therapy, but hypertonic saline has proven to

be at least as effective as mannitol at reducing ICP

Hypertonic Saline

Mannitol

Mechanism

Increases serum sodium levels, making it more

hypertonic. Giving a bolus causes a gradient for

water to follow sodium extracellularly and move out

of the cerebral spaces into the vasculature, while a

continuous infusion aids in resuscitation

Osmotic diuretic by increasing the osmolality of

the glomerular filtrate, thus blocking reabsorption

of water and excretion of sodium. This leads to

movement of water to extracellular and vascular

spaces and reducing the ICP

Dose

3 – 23.4% available

3%: optimal dose is unclear, reasonable to start with

300-500mL bolus or continuous infusion at 100mL/hr

and titrate per response

• 4% : 0.43-0.5 mL/kg IV bolus, max 30mL/dose

5 – 25% solutions available (20% most common)

• 25 – 1g/kg/dose IV bolus q 6-8 hours

(Usually 25-100g per dose)

Administration

3% intermittent bolus or continuous infusion

*strong osmotic gradient not retained with continuous infusions

• 4% intermittent bolus over 15 minutes

Intermittent IV infusion over 30 minutes

Adverse Effects

Hypervolemia, respiratory distress, electrolyte

imbalances (hypernatremia)

Hypotension, hypovolemia, AKI, electrolyte

disturbances (specifically K+), extravasation

Cautions/Pearls

Solutions > 3-5% require a central line

Requires in-line filter due to risk of crystallization

Avoid in hypovolemia and anuria

Patient population to

consider use in

Hypovolemic, hypotensive, traumatic resuscitation

Euvolemia, hypertensive, fluid restrictions

Monitoring

Serum sodium 145-155mEq/dL

Author, year

Design/ sample

size

Intervention & Comparison

Outcome

A. Kerwin,

2009

Retrospective

analysis,

(22 patients)

HTS vs mannitol

mean ICP reduction in patients

with TBI

HTS is as efficacious as mannitol, if not more so, and adds to

the growing literature suggesting that HTS is an effective

modality for the control of elevated ICP in patients with

severe TBI

M. Li, 2015

Meta-Analysis,

7 studies

(169 patients)

HTS vs mannitol in mean ICP

reduction in patients with TBI

HTS reduces ICP more effectively than mannitol in the setting

of TBI

S. Burgess,

2016

Meta-Analysis,

7 trials

(191 patients)

HTS vs mannitol in mean ICP

reduction, risk of ICP treatment

failure, mortality rates, and

neurological outcomes

No statistical difference in mortality and neurological

outcomes. No difference in mean reduced ICP; decreased

risk of ICP treatment failure with HTS

E. Berger-

Pelleiter,

2016

Meta-Analysis,

11 studies

Gu J, et al. Neurosurg Rev. 2018;42:499.

Berger-Pelleiter E, et al. CJEM. 2016;18:112-120.

Farrokh S, et al. Curr opin crit care. 20119; 25:105-109.

Witherspoon B, et al. Nurs Clin N Am. 2017;52:249-60.

Micromedex [Electronic].Greenwood Village, CO: Truven Health Analytics. Retrieved August 12, 2019 from

http://www.micromedexsolutions.com

Burgess S, et al. Annals of pharmacotherapy. 2016;50(4):291-300.

Li M, et al. Y, 2015. Medicine. 2015;9(4):17.

Dastur C, et al. Stroke and vascular neurology. 2017;2:21-29.

Kerwin A, et al. J Trauma. 2009;67:277-282.

Pasarikovski C, et al. World Neurosurg. 2017;105:1-6.

Gu J, et al. Neurosurg Rev. 2018;42:499.

Berger-Pelleiter E, et al. CJEM. 2016;18:112-120.

Farrokh S, et al. Curr opin crit care. 20119; 25:105-109.

Witherspoon B, et al. Nurs Clin N Am. 2017;52:249-60.

Micromedex [Electronic].Greenwood Village, CO: Truven Health Analytics. Retrieved August 12, 2019 from

http://www.micromedexsolutions.com