Early mannitol administration improves clinical outcomes of pediatric patients with brain edema
AbstractBackground: Mannitol 20% is used to treat patients with decreased consciousness and as the first line of treatment to reduce intracranial pressure (ICP). However, its application in pediatric patients is still based on minimal evidence. This study was performed to determine the predictive factors of clinical outcomes in pediatric patients with brain edema in the pediatric intensive care unit (PICU).
Methods: This prospective cohort study was conducted in the PICU, Sanglah Hospital Denpasar, Bali, Indonesia. The subjects were chosen by consecutive sampling from July 2016 to July 2017. The primary outcome variable was the patientâ€™s clinical outcome. A chi-square test was used to evaluate the association between the timing of mannitol administration and the patientâ€™s clinical outcome. Multivariate analysis was performed on all variables with pâ‰¤0.25.
Results: Forty-one patients were included in the study, 65% of them were male, 65% had good nutritional status, 90% had non-traumatic brain injury, and 73% had confirmed intracranial infection. The risk of sequelae or death for patients in a coma was 1.8 times greater than that of non-comatose patients (p=0.018; CI 95% 1.119â€“3.047). Based on the timing of mannitol administration from the onset of decreased consciousness, the risk of sequelae or death in patients who received mannitol after 24 hours was 2.1 times higher than that in patients who received mannitol within 24 hours (p=0.006; CI 95% 1.167â€“3.779). Based on multivariate analysis, only two variables were associated with the patientâ€™s clinical outcome: pediatric Glasgow coma scale (PGCS) â‰¤3 (p=0.03) and timing of mannitol administration >24 hours (p=0.01).
Conclusion: Early administration (<24 hours) of mannitol and high PGCS are related to favorable outcomes in patients with brain edema in the PICU.
Gwer S, Gatakaa H, Mwai L, Idro R, Newton CR. The role of osmotic agents in children with acute encephalopathies: a systematic review. BMC Pediatr. 2010;10:23. https://doi.org/10.1186/1471-2431-10-23
Oertel M, Kelly DF, Lee JH, McArthur DL, Glenn TC, Vespa P, et al. Efficacy of hyperventilation, blood pressure elevation, and metabolic suppression therapy in controlling intracranial pressure after head injury. J Neurosurg. 2002;97(5):1045â€“53. https://doi.org/10.3171/jns.2002.97.5.1045
Nara I, Shiogai T, Hara M, Saito I. Comparative effects of hypothermia, barbiturate, and osmotherapy for cerebral oxygen metabolism, intracranial pressure, and cerebral perfusion pressure in patients with severe head injury. Acta Neurochir Suppl. 1998;71:22â€“6. https://doi.org/10.1007/978-3-7091-6475-4_7
Tavakkoli F. Proceedings of the 18th expert committee on the selection and use of essential medicines; 2011 March 21-25; Baltimore, Maryland. USA.
Michinaga S, Koyama Y. Pathogenesis of brain edema and investigation into anti-edema drugs. Int J Mol Sci. 2015;16(5):9949â€“75. https://doi.org/10.3390/ijms16059949
Shawkat H, Westwood MM, Mortimer A. Mannitol: a review of its clinical uses. Contin Educ Anaesth Crit Care Pain. 2012;12(2):82â€“5. https://doi.org/10.1093/bjaceaccp/mkr063
Mohanty S, Mishra SK, Patnaik R, Dutt AK, Pradhan S, Das B, et al. Brain swelling and mannitol therapy in adult cerebral malaria: a randomized trial. Clin Infect Dis. 2011;53(4):349â€“55. https://doi.org/10.1093/cid/cir405
Jha SK. Cerebral edema and its management. Med J Armed Forces India. 2003;59(4):326â€“31. https://doi.org/10.1016/S0377-1237(03)80147-8
Wani AA, Ramzan AU, Nizami F, Malik NK, Kirmani AR, Bhatt AR, et al. Controversy in use of mannitol in head injury. Indian J Neurotrauma. 2008;5(1):11â€“3. https://doi.org/10.1016/S0973-0508(08)80022-6
Cruz J, Minoja G, Okuchi K, Facco E. Successful use of the new high-dose mannitol treatment in patients with Glasgow Coma Scale scores of 3 and bilateral abnormal pupillary widening: a randomized trial. J Neurosurg. 2004;100(3):376â€“83. https://doi.org/10.3171/jns.2004.100.3.0376
Li J, Wang B. Hyperosmolar therapy for the intracranial pressure in neurological practice: mannitol versus hypertonic saline. IJAR. 2013;1:56â€“61. https://doi.org/10.1097/MCC.0b013e32835eba30
Marcin JP, Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J, et al. Factors associated with adverse outcomes in children with diabetic ketoacidosis-related cerebral edema. J Pediatr. 2002;141(6):793â€“7. https://doi.org/10.1067/mpd.2002.128888
Copyright (c) 2018 Putu A. Sekarningrum, Dyah K. Wati, IGN Made Suwarba, I Nyoman B. Hartawan, Dewi S. Mahalini, IB Gede Suparyatha
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Authors who publish with Medical Journal of Indonesia agree to the following terms:
- Authors retain copyright and grant Medical Journal of Indonesia right of first publication with the work simultaneously licensed under a Creative Commons Attribution-NonCommercial License that allows others to remix, adapt, build upon the work non-commercially with an acknowledgment of the work’s authorship and initial publication in Medical Journal of Indonesia.
- Authors are permitted to copy and redistribute the journal's published version of the work non-commercially (e.g., post it to an institutional repository or publish it in a book), with an acknowledgment of its initial publication in Medical Journal of Indonesia.