MANNITOL

Dr.Mercy J.A,
II Anesthesiology,
Chengalpattu Medical College.
Introduction
• Mannitol (A carbohydrate derivative) introduced by Wise and
Chater in 1962
• Most widely used agent as osmotic diuretics.
• Mannitol is a naturally befalling sugar alcohol. Mannitol is a
hexahydroxy alcohol related to mannose. It occurs as a white,
crystalline powder and is soluble in water and stable at room
temperature
• Mannitol does not penetrate cells, and clearance from the
plasma is by glomerular filtration.
• Mannitol is a scavenger of oxygen-free radicals, which may
limit cellular swelling and decrease renal tubular interference.
• Mannitol has become the mainstay of ICP management
protocols.
• An osmotic diuretic, mannitol draws dihydrogen
monoxide from the brain and other tissues into the
intravascular compartment.
• Mannitol lower ICP by decreasing blood viscosity
and expanding plasma volume that increase CBF
(cerebral blood flow).
• When autoregulation is intact, this prompts
vasoconstriction to renovate CBF to normal
• Mannitol is widely utilized in the management of
raised intracranial pressure (ICP)
• Also used in cardiac, vascular, and renal
transplantation surgery, and in the management of
rhabdomyolysis, bowel preparation before colorectal
surgery
Mechanism of Action:
• In Proximal Tubule:
 Retains water isosmotically in PT dilutes luminal fluid which
opposes NaCl reabsorption.
• In Loop of Henle:
 Inhibits transport process in the tick AscLH by an unknown
mechanism.
 Major site of action is loop of Henle.
• Medullary Osmotic Gradient & Renal Blood Flow:
 By extracting water from intercellular compartments, osmatic
diuretics expand the extracellular fluid volume, decrease blood
viscosity, and inhibit renin release.
 These effects increase RBF.
 And the increase in renal medullary blood flow removes NaCl and
urea from the renal medulla, thus reducing medullary tonicity.
Dose of Mannitol
• The conventional osmatic agent mannitol, when
administrated at a dose of 0.25 to 1.5 g/kg by
intravenous bolus injection, usually lowers ICP,
with maximal effects observed 20 to 40 minutes
following its administration.
• Repeated dosing of Mannitol may be instituted
every 6 hours and should be guided by serum
osmolality to a recommended target value of
approximately 320 mOsm/l; higher valued result
in renal tubular damage.
Diuretics
• Mannitol is commonly used in neuro-anaesthesia as a hypertonic
infusion to reduce intracranial pressure and volume.
• It achieves the present by its osmotic action producing brain
shrinkage and vasoconstriction subsequent to a decline in
viscosity.
• Duration of action is 10-60 mins . The larger dose may last longer.
• provided the ultimate importance of promoting the CBF to
preventing cerebral ischemia.
• In unconscious head injured patient should be given the mannitol
approximately 1.5gm/kg as shortly as is possible.
• Rapid administration of mannitol produce profound hypotension
(not hypertension) and should be administered over 20 min.
• Other important side effect of rapid administration of mannitol is
transient hyperkalemia.
Local Anaesthesia [New Concept]
• The composition is a mixture of a local
anesthetic agent and a sugar alcohol (Mannitol).
The sugar alcohol opens the protective covering
of sensory nerves, allowing the anesthetic agent
to enter the innermost parts of the nerves it is
meant to numb or anaesthetized.
• Mannitol permits heightened permeability
improving the success of inferior alveolar nerve
block when administered concurrently.
Cerebral effects
• Mannitol does not cross the blood brain barrier
• An elevated plasma osmolality due to an infusion of
hypertonic mannitol is efficient in eliminating fluid from the
brain. This is called ‘mannitol osmotherapy’.
• Mannitol admixtures decrease elevated intracranial pressure
due to an intracranial outer space residing lesion. A standard
application would be in a patient with intracerebral
hematoma due to intense traumatic head injury.
• The outcome is rapid in onset ,temporary (as the mannitol is
excreted)
• Its use acquires time for critical definitive therapy.
OSMOTIC EFFECT OF MANNITOL:

• Hypertonicity osmotic effect of mannitol

causes Intracellular dehydration, Expansion of
ECF volume (except brain ECF)
• Hemodilution and Diuresis due osmotic effects
and ECF expansion.
NON-OSMOTIC EFFECTS OF
MANNITOL:
• Decreased blood viscosity (with enhanced tissue blood movement) with
Possible Cytoprotective consequence (due to free radical scavenging)
• Cardiovascular consequences are subsequent to expanded intravascular
volume (e.g., increased cardiac output, hypertension, heart failure,
pulmonary oedema).
• Mannitol damage endothelial cells and activate coagulation pathways
leading to intravascular thrombosis.
• Dehydration and hemagglutination have also been associated with
mannitol use.
• Use of hypertonic mannitol as an osmotic agent was reported with
success by Barry et al. in cases with functional renal failure and oliguria
and has since then had been an accepted part of therapy. Mannitol was
also found a very effective agent for reducing cerebro-spinal fluid
pressure.
Mannitol in Cataract Surgery
• Mannitol effectively used earlier to lower intra-ocular
pressure.
• Intravenous administration of mannitol induces diuresis
by elevating the osmotic pressure of the glomerular
filtrate to such an extent that tubular re-absorption of
water and sodium is hindered.
• Mannitol also promotes excretion of chlorides.
• Reduction of intra-ocular pressure prior to cataract
surgery is essential to keep vitreous in its “physiological
position” after lens extraction and to minimize post-
operative complications.
Mannitol in Bowel Analysis
• The small bowel has always been a challenging area to assess for
surgeons and gastroenterologists owing to its long length and
complexity of the loops.
• Yesteryear’s barium investigations were most often non-specific
with a very low diagnostic yield. Technological advances in
multidetector computed tomography (MDCT) have revolutionized
imaging field and have added new concepts to solid and hollow
viscera imaging.
• The success of accurate interpretation of bowel pathologies
requires an optimal preparation and acquisition. This requires an
oral contrast agent, which should cause uniform intraluminal
attenuation, high contrast between luminal content and bowel wall,
minimal mucosal absorption leading to maximum distension,
absence of artifact formation and no significant adverse effects .
• Mannitol as endoluminal contrast increases the diagnostic
accuracy of the investigative studies in comparison to
water and iodine-based contrast by producing
significantly better bowel distension and visibility of mural
features with improved image quality without additional
adverse effects.
• Mannitol proved to be better both quantitatively and
qualitatively in bringing out small and large bowel
distension, delineation of wall, IC valve visualization, and in
providing improved overall image quality. It is also a cheap,
effective, and well tolerated endoluminal contrast agent with
minimal adverse effects .
MANNITOL ROLE IN PIH
• PRES is the core component of the pathogenesis of eclampsia. The term
PRES ,the syndrome can involve or extend beyond the posterior cerebrum. It
occurs secondary to failure of autoregulatory response to acute changes in
blood pressure. As term suggests, it resolves completely if treated appropriately,
but some can progress to develop permanent neurological defects.
• PRES is an illness in which a person can present with acutely altered
mentation, drowsiness or sometimes stupor, visual impairment (e.g., visual
hallucinations, cortical blindness, hemianopia and diplopia), seizures (focal or
general tonic-clonic), and sudden or constant, non-localized headaches.
• PRES can unfold acutely or subacutely, with symptoms developing within
hours to days.
• Often, the presentation occurs in the context of acute uncontrolled
hypertension, with systolic blood pressures ranging between 160 to 190 mmHg.
• Unique neuroimaging findings of vasogenic edema involving the posterior
circulation
• Inj. Mannitol was administered in cases who did not
respond to Inj. MgSO4 alone and had either recurrent
convulsions, extreme irritability, visual disturbances or
severe or deep coma.
• Dose Inj. Mannitol was administered 100 ml of 20%
IV. 6 hourly for 48 h, and then, it was tapered 8 hourly
for next 24 h, 12 hourly for next 24 h and then omitted.
• Inj. Mannitol would help to revert the neurological
signs like cerebral edema and result in dramatic
recovery.
MANNITOL IN TRANSFUSION
REACTIONS

• Renal shutdown is a most serious complication of

transfusion reactions.
• Urine flow is a reliable indicator of renal function in
patients during stress and should be considered a vital
sign.
• When oliguria is observed resuscitative procedures,
mannitol infusion, should be applied promptly.
• Mannitol is capable of restoring sufficient renal
function to prevent the complications and mortality
associated with oliguric renal failure.
MANNITOL IN HIBD
• Brain edema after hypoxic-ischemic brain damage (HIBD) is a
serious problem.
• Mannitol can mitigate edema
• Vasogenic edema contributed to brain swelling during HIBD.
• Brain water content analysis indicated that mannitol could relief
brain edema induced by HIBD after 6 h.
• Aquaporin-4 (AQP4), a member of the water channel protein
family, plays a vital role in the development of brain edema.
• Mannitol alleviate brain edema by upregulating the expression
of AQP4.
• Mannitol upregulated the expression of AQP4 in the first 48 h
following HIBD induction.
Side Effects:
• When given orally causes osmatic diarrhoea
• Dehydration, Hyperkalaemia,and Hypernatremia
 Excessive use of mannitol without adequate water
replacement can ultimately lead to serve dehydration, free
water losses, and hypernatremia
 As water is extracted from cells, intracellular concentration
rises, leading to cellular losses and hyperkalaemia.
 These complications can be avoided by careful attention to
serum ion composition and fluid balance
• Extracellular Volume Expansion
– Mannitol is rapidly distributed in the extracellular
compartment and extracts water from cells
– Prior to the diuresis this leads to expansion of the
extracellular volume and hyponatremia
– This effect can complicate heart failure and may
produce fluid pulmonary enema
• Headache, nausea and vomiting are commonly
observed in patients treated with osmatic