Mannitol ,Furosemide or

Hypertonic Saline in Management

of Increased Intracranial Pressure
Splachnic Brain

Diah Mustika HW dr,SpN,KIC

JCCA, 20 Maret 2022
Intracranial Component
 AUTOREGULATION
• Maintain the cerebral perfusion pressure (CPP)
• Effective at MAP 60-150 mmHg
• CBF = CPP (MAP-ICP)
CVR
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 MANAGEMENT
• Elevation of head 30o
• Analgesia and sedation
• Hyperventilation
• Maintain : blood pressure, volume status,
body temperature, CPP
• Monitoring : haemoglobin, blood glucose,
sodium
• Hyperosmolar therapy
 OSMOLALITY

2(Na+K) + GD/18 + BUN/2,8

OR

2(Na+K) + GD/18 + Ur/6,4

Keep Osmolality between 310-320 mOsm/L

COMPARATION OF HYPEROSMOLAR
THERAPY
 MANNITOL 20%
• Dose : 0,25 – 1gr/kgBB every 3-6
hours over 15-30 minutes
• Infuse via peripheral line, central line
• Monitoring :
– ICP (goal <20 mmHg)
– Hypovolemia
– Serum osmolality (<325 mOsm)
• Contraindication : Renal failure, CHF
HYPERTONIC SALINE 3% BOLUS

• Dose : 250 ml IV every 3-6 hours over

20-30 minutes
• Infuse via central line
• In a emergency, HTS 3% may
administered via infuse via peripheral line
• Monitoring :
– ICP (goal <20 mmHg)
– Serum sodium (<155 mEq/L)
HYPERTONIC SALINE 3% INFUSION

• Dose : 50 - 150 ml/hours

• Infuse via central line
• Monitoring :
– ICP (goal <20 mmHg),
– Serum sodium (<155 mEq/L)
– Serum osmolality (<325 mOsm)
 HYPERTONIC SALINE 23,4%

• Dose: 30ml every 3-6 hours over 15 – 30

minutes
• Infusion via central line
• Monitoring :
– ICP (goal <20 mmHg)
– Serum sodium (goal <155 mE q/L)
– Central pontine myelinolysis
 FUROSEMIDE

• Dose : 1mg/kgBB every 8 hours

• Better administration if combine with
mannitol
• Contraindication : Hypotension
 MANNITOL VS HTS 3% (1)
Mannitol HTS 3%

Primary - Increases gradient across - Increases gradient across

mechanism BBB BBB
- Rapid reduction of ICP - Immediate reduction of ICP
- Duration : 6 hours - Duration : 4 hours
Secondary - Cerebral vasoconstriction - Mixed immunomodulatory and
Mechanism - Decreases blood viscosity antiinflamatory effects
- Increases cerebral blood
flow

Hemodynamic - Transient expansion of - Expand intravascular volume

effects intravascular volume - Increases MAP
- Brisk osmotic diuresis
 MANNITOL VS HTS 3% (2)
Mannitol HTS 3%

Adverse event - Acute Kidney Injury - Osmotic demyelination

- Dehydration syndrome
- Hypotension - Fluid overload
- Electrolite Imbalances - Hyperchloremic metabolic
- Rebound ICP acidosis
- Hyperoncotic hemolysis
Monitoring - Through osmolar gap (<20 - Serum sodium every 4-6
mOsm/kg) hours
- Renal function - Hypernatremia goal (<155
- Electrolytes mEq/L)
 CONCLUSION

• Elevation of ICP can be treated with

hyperosmolar therapy such as Mannitol
20% or HTS 3%
• Even it still controversial, administration of
HTS 3% is superior than mannitol 20%
• Furosemide can administered as
concomitant therapy to reduce ICP
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