title: Mannitol for acute traumatic brain injury.
abstract: BACKGROUND
  Mannitol is sometimes dramatically effective in reversing acute brain swelling, but its effectiveness in the on-going management of severe head injury remains open to question. There is evidence that in prolonged dosage mannitol may pass from the blood into the brain, where it might cause reverse osmotic shifts that increase intracranial pressure.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  The review drew on the search strategy for the Injuries Group as a whole. We checked reference lists of trials and review articles, and contacted authors of trials.
  
  
  METHODS
  Randomised 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. Trials where the intervention was started more than eight weeks after injury, and cross-over trials were excluded.
  
  
  METHODS
  The reviewers 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.
  
  
  RESULTS
  Overall there were few eligible trials. There were no trials comparing different doses, or type of administration. One trial compared ICP-directed therapy to 'standard care' (RR for death= 0.83; 95% CI 0.47;1.46). One trial compared mannitol to pentobarbital (RR for death = 0.85; 95% CI 0. 52;1.38). No trials compared mannitol to other ICP lowering agents. One trial tested the effectiveness of pre-hospital administration of mannitol against placebo (RR for death=1.59; 95% CI 0.44;5.79).
  
  
  CONCLUSIONS
  There are insufficient data to recommend one form of mannitol infusion over another. Mannitol therapy for raised ICP may have a beneficial effect on mortality when compared to pentobarbital treatment. 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 to preclude either a harmful or a beneficial effect on mortality.
authors.affiliation: 7 Barton Road, Greenside, Johannesburg 2193, South Africa. gillsch@mweb.co.za
authors.forename: G
authors.initials: G
authors.lastname: Schierhout
authors.forename: I
authors.initials: I
authors.lastname: Roberts
mesh_terms: D001930:Brain Injuries / Q000150:complications / Q000188:drug therapy*; D004234:Diuretics, Osmotic / Q000627:therapeutic use*; D006801:Humans; D019586:Intracranial Hypertension / Q000209:etiology / Q000517:prevention & control*; D008353:Mannitol / Q000627:therapeutic use*
chemical_list: D004234:Diuretics, Osmotic; D008353:Mannitol