title: A comparison of equivolume, equiosmolar solutions of hypertonic saline and mannitol for brain relaxation during elective supratentorial craniotomy.
abstract: BACKGROUND
  Hyperosmolar solutions have been used in neurosurgery to reduce brain volume and facilitate surgical exposure. The purpose of this study was to compare the effects of equivolume, equiosmolar solutions of mannitol and hypertonic saline (HS) on brain relaxation, intensive care unit (ICU) and hospital stay, postoperative outcomes and incidence of side-effects in patients undergoing elective supratentorial craniotomy.
  
  
  METHODS
  In a randomised, prospective, double-blind study, 60 patients undergoing elective supratentorial craniotomy were randomised 1:1 to receive 3 ml/kg of either 20% mannitol or 3% HS. The primary outcome was the surgical condition of the brain assessed by the neurosurgeon using a 4-point scale after opening the dura (1 = relaxed, 2 = satisfactory, 3 = firm and 4 = bulging). Secondary outcomes were electrolytes, blood gases, plasma osmolality and haemodynamic variables measured at 0 min, 30 min, 2 h and 6 h after infusion. Also, predefined postoperative complications, length of ICU and hospital stay were recorded. Appropriate statistical tests were used for comparison; p < 0.05 was considered significant.
  
  
  RESULTS
  There was no difference in brain relaxation [mannitol, 1(1-3) versus HS, 1(1.4) points; p = 0.55]. Patients with brain midline shift showed a worse response to hyperosmolar solutions than those without midline shift: 37% versus 8%, respectively; OR = 6.6 (95% CI, 1.54-28.83); p = 0.006. Plasma osmolality increased during the study period (6 h) in both the groups (p < 0.05 compared with baseline). No significant differences in postoperative complications or length of ICU and hospital stay were observed between the groups.
  
  
  CONCLUSIONS
  Single doses of 3 ml/kg of 20% mannitol and 3% HS are safe and effective for intraoperative brain debulking during elective supratentorial craniotomy, but less effective in patients with pre-existing mass effect and midline shift.
authors.affiliation: a Department of Anaesthesia , Hospital Universitario "Virgen de la Arrixaca" , Murcia , Spain ;
authors.forename: Joaquín
authors.initials: J
authors.lastname: Hernández-Palazón
authors.affiliation: a Department of Anaesthesia , Hospital Universitario "Virgen de la Arrixaca" , Murcia , Spain ;
authors.forename: Diego
authors.initials: D
authors.lastname: Fuentes-García
authors.affiliation: a Department of Anaesthesia , Hospital Universitario "Virgen de la Arrixaca" , Murcia , Spain ;
authors.forename: Paloma
authors.initials: P
authors.lastname: Doménech-Asensi
authors.affiliation: b Department of Neurosurgery , Hospital Universitario "Virgen de la Arrixaca" , Murcia , Spain.
authors.forename: Claudio
authors.initials: C
authors.lastname: Piqueras-Pérez
authors.affiliation: a Department of Anaesthesia , Hospital Universitario "Virgen de la Arrixaca" , Murcia , Spain ;
authors.forename: Luis
authors.initials: L
authors.lastname: Falcón-Araña
authors.affiliation: a Department of Anaesthesia , Hospital Universitario "Virgen de la Arrixaca" , Murcia , Spain ;
authors.forename: Sebastián
authors.initials: S
authors.lastname: Burguillos-López
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001921:Brain / Q000187:drug effects / Q000601:surgery*; D003399:Craniotomy / Q000009:adverse effects; D004311:Double-Blind Method; D017558:Elective Surgical Procedures / Q000009:adverse effects; D005260:Female; D006801:Humans; D007427:Intracranial Pressure / Q000187:drug effects; D008297:Male; D008353:Mannitol / Q000494:pharmacology*; D008875:Middle Aged; D019635:Neurosurgical Procedures; D011446:Prospective Studies; D012462:Saline Solution, Hypertonic / Q000494:pharmacology; D055815:Young Adult
chemical_list: D012462:Saline Solution, Hypertonic; D008353:Mannitol
keywords: brain relaxation; craniotomy; hypertonic saline; mannitol; neurosurgery; supratentorial tumour