title: Mannitol dosing error during interfacility transfer for intracranial emergencies.
abstract: OBJECTIVE
  Mannitol is commonly used to treat elevated intracranial pressure (ICP). The authors analyzed mannitol dosing errors at peripheral hospitals prior to or during transport to tertiary care facilities for intracranial emergencies. They also investigated the appropriateness of mannitol use based on the 2007 Brain Trauma Foundation guidelines for severe traumatic brain injury.
  
  
  METHODS
  The authors conducted a retrospective review of the Shock Trauma Air Rescue Society (STARS) electronic patient database of helicopter medical evacuations in Alberta, Canada, between 2004 and 2012, limited to patients receiving mannitol before transfer. They extracted data on mannitol administration and patient characteristics, including diagnosis, mechanism, Glasgow Coma Scale score, weight, age, and pupil status.
  
  
  RESULTS
  A total of 120 patients with an intracranial emergency received a mannitol infusion initiated at a peripheral hospital (median Glasgow Coma Scale score 6; range 3-13). Overall, there was a 22% dosing error rate, which comprised an underdosing rate (<0.25 g/kg) of 8.3% (10 of 120 patients), an overdosing rate (>1.5 g/kg) of 7.5% (9 of 120), and a nonbolus administration rate (>1 hour) of 6.7% (8 of 120). Overall, 72% of patients had a clear indication to receive mannitol as defined by meeting at least one of the following criteria based on Brain Trauma Foundation guidelines: neurological deterioration (11%), severe traumatic brain injury (69%), or pupillary abnormality (25%).
  
  
  CONCLUSIONS
  Mannitol administration at peripheral hospitals is prone to dosing error. Strategies such as a pretransport checklist may mitigate this risk.
authors.affiliation: Division of Neurosurgery, University of Alberta, and.
authors.forename: Cameron A
authors.initials: CA
authors.lastname: Elliott
authors.affiliation: Department of Emergency Medicine, Royal Alexandra Hospital, Edmonton, Alberta, Canada.
authors.forename: Mark
authors.initials: M
authors.lastname: MacKenzie
authors.affiliation: Division of Neurosurgery, University of Alberta, and.
authors.forename: Cian J
authors.initials: CJ
authors.lastname: O'Kelly
mesh_terms: D000367:Age Factors; D017732:Air Ambulances; D000416:Alberta; D001930:Brain Injuries / Q000150:complications* / Q000188:drug therapy / Q000628:therapy; D005260:Female; D015600:Glasgow Coma Scale; D019983:Guideline Adherence; D006801:Humans; D020300:Intracranial Hemorrhages / Q000628:therapy; D019586:Intracranial Hypertension / Q000188:drug therapy; D008297:Male; D008353:Mannitol / Q000008:administration & dosage* / Q000009:adverse effects* / Q000627:therapeutic use; D019300:Medical Errors; D008875:Middle Aged; D011680:Pupil; D012189:Retrospective Studies; D014187:Transportation of Patients / Q000379:methods*; D016896:Treatment Outcome
chemical_list: D008353:Mannitol
keywords: BTF = Brain Trauma Foundation; GCS = Glasgow Coma Scale; ICP = intracranial pressure; STARS = Shock Trauma Air Rescue Society; dosing error; mannitol; medical evacuation; trauma