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
  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.
  
  
  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: Emergency Care Research Unit (ECRU), Division of Population Health Sciences (PHS), Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin 2, Ireland.
authors.forename: Abel
authors.initials: A
authors.lastname: Wakai
authors.forename: Aileen
authors.initials: A
authors.lastname: McCabe
authors.forename: Ian
authors.initials: I
authors.lastname: Roberts
authors.forename: Gillian
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* / Q000009:adverse effects; D006801:Humans; D019586:Intracranial Hypertension / Q000209:etiology / Q000517:prevention & control*; D007427:Intracranial Pressure / Q000187:drug effects; D008353:Mannitol / Q000008:administration & dosage* / Q000009:adverse effects; D010424:Pentobarbital / Q000008:administration & dosage; D016032:Randomized Controlled Trials as Topic; D012462:Saline Solution, Hypertonic / Q000008:administration & dosage
chemical_list: D004234:Diuretics, Osmotic; D012462:Saline Solution, Hypertonic; D008353:Mannitol; D010424:Pentobarbital
references.citation: J Trauma. 1995 Dec;39(6):1091-7; discussion 1097-9
references.pmid: 7500400
references.citation: J Neurotrauma. 1996 Nov;13(11):641-734
references.pmid: 8941879
references.citation: Neurosurgery. 1979 Nov;5(5):570-5
references.pmid: 534065
references.citation: J Neurosurg. 1986 Dec;65(6):820-4
references.pmid: 3095507
references.citation: Crit Care Med. 1995 Mar;23(3):560-7
references.pmid: 7874910
references.citation: Neurosurgery. 2002 Sep;51(3):628-37; discussion 637-8
references.pmid: 12188940
references.citation: Acad Emerg Med. 1996 Sep;3(9):840-8
references.pmid: 8870755
references.citation: Intensive Care Med. 2009 Mar;35(3):471-9
references.pmid: 18807008
references.citation: Crit Care Med. 2008 Mar;36(3):795-800
references.pmid: 18209674
references.citation: Crit Care Med. 1996 Oct;24(10):1743-8
references.pmid: 8874315
references.citation: BMJ. 1996 Apr 13;312(7036):944-7
references.pmid: 8616307
references.citation: Can J Neurol Sci. 1984 Nov;11(4):434-40
references.pmid: 6440704
references.citation: Neurosurgery. 2001 Oct;49(4):864-71
references.pmid: 11564247
references.citation: Crit Care Med. 2003 Jun;31(6):1683-7
references.pmid: 12794404
references.citation: J Neurosurg. 2004 Mar;100(3):376-83
references.pmid: 15035271
references.citation: Crit Care Med. 2005 Jan;33(1):196-202; discussion 257-8
references.pmid: 15644669
references.citation: Crit Care. 2005 Oct 5;9(5):R530-40
references.pmid: 16277715