title: Mannitol for acute traumatic brain injury.
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.
  
  
  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. The searches were last updated in March 2006.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  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).
  
  
  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.
authors.affiliation: St Vincent's Hospital, Department of Emergency Medicine, Dublin 4, Ireland. wakai@indigo.ie
authors.forename: A
authors.initials: A
authors.lastname: Wakai
authors.forename: I
authors.initials: I
authors.lastname: Roberts
authors.forename: G
authors.initials: G
authors.lastname: Schierhout
mesh_terms: D000208:Acute Disease; D001930:Brain Injuries / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D004234:Diuretics, Osmotic / Q000008:administration & dosage*; D006801:Humans; D019586:Intracranial Hypertension / Q000209:etiology / Q000517:prevention & control*; D008353:Mannitol / Q000008:administration & dosage*; D016032:Randomized Controlled Trials as Topic
chemical_list: D004234:Diuretics, Osmotic; D008353:Mannitol