This is not the most recent version of the article. View current version (5 AUG 2013)

Intervention Review

You have free access to this content

Mannitol for acute traumatic brain injury

  1. Abel Wakai1,*,
  2. Ian G Roberts2,
  3. Gillian Schierhout3

Editorial Group: Cochrane Injuries Group

Published Online: 24 JAN 2007

Assessed as up-to-date: 28 FEB 2006

DOI: 10.1002/14651858.CD001049.pub4


How to Cite

Wakai A, Roberts IG, Schierhout G. Mannitol for acute traumatic brain injury. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD001049. DOI: 10.1002/14651858.CD001049.pub4.

Author Information

  1. 1

    Sunnybrook Health Sciences Centre, Division of Emergency Medicine, Toronto, Ontario, Canada

  2. 2

    London School of Hygiene & Tropical Medicine, Cochrane Injuries Group, London, UK

  3. 3

    London School of Hygiene & Tropical Medicine, c/o Cochrane Injuries Group, London, UK

*Abel Wakai, Division of Emergency Medicine, Sunnybrook Health Sciences Centre, Suite C7-16, Toronto, Ontario, M4N 3M5, Canada. abelwakai@gmail.com.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 24 JAN 2007

SEARCH

This is not the most recent version of the article. View current version (05 AUG 2013)

 
Characteristics of included studies [ordered by study ID]
Sayre 1996

MethodsRandomised and double blind placebo controlled trial.


ParticipantsModerate and severe head injury (CGS 11 and less), above 18 years of age.


InterventionsMannitol received 5ml/kg of 20% mannitol through large-bore intravenous catheter over five minutes; placebo group were given5ml/kg of 0.9% saline solution.


OutcomesDeath was reported. Length of follow-up was two hours after hospital admission.


NotesTesting pre-hospital administration of mannitol.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate

Schwartz 1984

MethodsRandomised single blind trial.


ParticipantsSevere head injury (GCS<8). Participants had to have already been resuscitated and had raised ICP for more than 15 minutes.


InterventionsThe mannitol group received 20% mannitol solution at an initial dose of 1g per kg. Additional increments were given to maintain the intracranial pressure at less than 20 torr, within a serum osmolarity of mannitol of 320mOs/L.

The pentobarbital group received pentobarbital as an IV bolus of up to 10mg/kg, followed by a continuous infusion at 0.5-3 mg/kg/hr, provided that CPP remained above 50 torr, Additional increments of pentobarbital were given to maintain the intracranial pressure at less than 20 torr.


OutcomesDeath reported. Follow-up to three months.


NotesFor subsequent episodes of raised ICP, cross-over between the groups was allowed.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

Smith 1986

MethodsRandomised controlled trial; not reported as double-blind.


ParticipantsSevere head injury (GCS 8 or less).


InterventionsCompared two regimens of guiding the administration of mannitol, one according to neurological signs and physiological measurements, and the other using ICP monitoring. The protocol for the first group used neurological signs, GCS, ventilatory values and arterial blood gas to guide administration. In the second group, a 250ml bolus of mannitol (20%) was given if ICP >25mmHg, and subsequent boluses were given incrementally.


OutcomesDeaths and neurological disability were reported. Follow-up was one year.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearD - Not used

Vialet 2003

MethodsRandomised single blind trial.


ParticipantsSevere head injury (GCS<8) who required intravenous infusions of an osmotic agent to treat episodes of intracranial hypertension resistant to standard therapy.


InterventionsCompared two osmotic agents, mannitol and hypertonic saline solution. The mannitol group received 20% mannitol solution. The hypertonic saline group received 7.5% hypertonic saline. The infused volume was the same for both solutions: 2 ml/kg body weight in 20 minutes.


OutcomesDeath and neurological disability reported. Follow-up to three months.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Battison 2005Cross-over design.

Cruz 2001Concerns about the integrity of the trial data. Manuscripts does not indictate where the patients were randomised and despite an investigation by the Cochrane Injuries Group this remains open to question.

Cruz 2002Concerns about the integrity of the trial data. Manuscripts does not indictate where the patients were randomised and despite an investigation by the Cochrane Injuries Group this remains open to question.

Cruz 2004Concerns about the integrity of the trial data. Manuscripts does not indictate where the patients were randomised and despite an investigation by the Cochrane Injuries Group this remains open to question.

Fortune 1995Controlled follow up study; no means to reduce bias in the selection of the control group was used.

Gaab 1989Randomised to a diuretic, not necessarily mannitol.

Levin 1979Participants were not all head injured; had a cross-over design.

Midgely 1993Cross-over design.

Smedema 1993Not all head-injured patients.

 
Comparison 1. ICP-directed mannitol ('treatment') compared to mannitol according to neurological signs ('control')

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Death177Risk Ratio (M-H, Fixed, 95% CI)0.83 [0.47, 1.46]

 2 Death or severe disability177Risk Ratio (M-H, Fixed, 95% CI)0.88 [0.55, 1.38]

 
Comparison 2. Mannitol versus pentobarbital

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Death159Risk Ratio (M-H, Fixed, 95% CI)0.85 [0.52, 1.38]

 
Comparison 3. Mannitol versus hypertonic saline

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Death120Risk Ratio (M-H, Fixed, 95% CI)1.25 [0.47, 3.33]

 
Comparison 4. Mannitol versus placebo

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Death141Risk Ratio (M-H, Fixed, 95% CI)1.75 [0.48, 6.38]