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CC BY 4.0 · J Neuroanaesth Crit Care
DOI: 10.1055/s-0045-1802592
Original Article

Comparison of Effects of Intravenous 20% Mannitol versus Combination of 10% Mannitol and 10% Glycerol for Intraoperative Brain Relaxation in Neurosurgery

Singam Geetha 
1   Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
,
Krishna R. Maremanda 
1   Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
,
Vamsi Madduri
2   Sangamithra Hospitals, Ongole, Andhra Pradesh, India
,
Ventapalli S. Priya
1   Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
,
Padmaja Durga 
1   Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
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Abstract

Background: Pharmacological reduction in intraoperative brain bulk is commonly achieved using mannitol. Other hyperoncotic agents like glycerol are less frequently used due to reported intravascular hemolysis and hyperglycemia. A combination of glycerol 10% and mannitol 10% may limit the adverse effects of both agents. The study's objective was to compare the impact of mannitol 20% and the combination on intraoperative brain relaxation and their adverse effects.

Methods: Sixty adult patients undergoing elective supratentorial tumor removal by craniotomy were randomized to receive either 2.5 mL /kg of 20% mannitol (group M) or 10% mannitol + 10% glycerol (group C). Brain relaxation was assessed on the four-point scale after craniotomy, and hemodynamics, electrolyte, and blood sugar were measured up to 1 hour after infusion.

Results: Seventy-nine percent of patients in group M and 93% in group C had adequate brain relaxation (scale1 and 2; p = 0.108) There was no significant difference in hemodynamic and electrolyte changes. There was a significant increase in blood glucose in group C (mean: 13.1 mg% (standard deviation: 4.4). There was no difference in the length of intensive care unit and hospital stay. None of the patients had hemolysis or clinical evidence of rebound edema. There was no mortality in the groups.

Conclusion: The combination of 10% mannitol and 10% glycerol provides a safe and effective alternative to 20% mannitol for intraoperative reduction in intracranial pressure and reduction in brain bulk for providing suitable conditions for the removal of supratentorial tumors.

Keywords

osmotherapy - craniotomy - mannitol - glycerol - brain relaxation - adverse effects - hemolysis


Publication History

Article published online:
25 April 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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  • References

  • 1 Grande PO, Romner B. Osmotherapy in brain edema: a questionable therapy. J Neurosurg Anesthesiol 2012; 24 (04) 407-412
    PubMedSearch in Google Scholar
  • 2 Righetti E, Celani MG, Cantisani T, Sterzi R, Boysen G, Ricci S. Glycerol for acute stroke. Review Cochrane Database Syst Rev 2004; 2004 (02) CD000096
    PubMedSearch in Google Scholar
  • 3 MacDonald JT, Uden DL. Intravenous glycerol and mannitol therapy in children with intracranial hypertension. Neurology 1982; 32 (04) 437-440
    PubMedSearch in Google Scholar
  • 4 Nau R. Osmotherapy for elevated intracranial pressure: a critical reappraisal. Clin Pharmacokinet 2000; 38 (01) 23-40
    CrossrefPubMedSearch in Google Scholar
  • 5 Shankar A. Clinical efficacy of mannitol (10%) with glycerine (10%) versus mannitol (20%) in cerebral oedema. J Neurol Stroke 2019; 9 (04) 222-227
    PubMedSearch in Google Scholar
  • 6 Li J, Gelb AW, Flexman AM, Ji F, Meng L. Definition, evaluation, and management of brain relaxation during craniotomy. Br J Anaesth 2016; 116 (06) 759-769
    CrossrefPubMedSearch in Google Scholar
  • 7 Paczynski RP. Osmotherapy. Basic concepts and controversies. Crit Care Clin 1997; 13 (01) 105-129
    PubMedSearch in Google Scholar
  • 8 Qureshi AI, Suarez JI. Use of hypertonic saline solutions in treatment of cerebral edema and intracranial hypertension. Crit Care Med 2000; 28 (09) 3301-3313
    CrossrefPubMedSearch in Google Scholar
  • 9 Harutjunyan L, Holz C, Rieger A, Menzel M, Grond S, Soukup J. Efficiency of 7.2% hypertonic saline hydroxyethyl starch 200/0.5 versus mannitol 15% in the treatment of increased intracranial pressure in neurosurgical patients - a randomized clinical trial [ISRCTN62699180]. [ISRCTN62699180] Crit Care 2005; 9 (05) R530-R540
    CrossrefPubMedSearch in Google Scholar
  • 10 Wang J, Ren Y, Wang SF. et al. Comparative efficacy and safety of glycerol versus mannitol in patients with cerebral oedema and elevated intracranial pressure: a systematic review and meta-analysis. J Clin Pharm Ther 2021; 46 (02) 504-514
    PubMedSearch in Google Scholar
  • 11 Pasarikovski CR, Alotaibi NM, Al-Mufti F, Macdonald RL. Hypertonic saline for increased intracranial pressure after aneurysmal subarachnoid hemorrhage: a systematic review. World Neurosurg 2017; 105: 1-6
    PubMedSearch in Google Scholar
  • 12 Shao L, Hong F, Zou Y, Hao X, Hou H, Tian M. Hypertonic saline for brain relaxation and intracranial pressure in patients undergoing neurosurgical procedures: a meta-analysis of randomized controlled trials. PLoS One 2015; 10 (01) 117314
    PubMedSearch in Google Scholar
  • 13 Freeman N, Welbourne J. Osmotherapy: science and evidence-based practice. BJA Educ 2018; 18 (09) 284-290
    CrossrefPubMedSearch in Google Scholar
  • 14 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 (Wien) 1998; 71: 22-26
    PubMedSearch in Google Scholar
  • 15 Yu YL, Kumana CR, Lauder IJ. et al. Treatment of acute cerebral hemorrhage with intravenous glycerol. A double-blind, placebo-controlled, randomized trial. Stroke 1992; 23 (07) 967-971
    PubMedSearch in Google Scholar
  • 16 Singhi S, Järvinen A, Peltola H. Increase in serum osmolality is possible mechanism for the beneficial effects of glycerol in childhood bacterial meningitis. Pediatr Infect Dis J 2008; 27 (10) 892-896
    PubMedSearch in Google Scholar
  • 17 Gwer S, Gatakaa H, Mwai L, Idro R, Newton CR. The role for osmotic agents in children with acute encephalopathies: a systematic review. BMC Pediatr 2010; 10: 23
    PubMedSearch in Google Scholar
  • 18 Wall EC, Ajdukiewicz KM, Heyderman RS, Garner P. Osmotic therapies added to antibiotics for acute bacterial meningitis. Cochrane Database Syst Rev 2013; 3 (03) CD008806
    PubMedSearch in Google Scholar
  • 19 Biestro A, Alberti R, Galli R. et al. Osmotherapy for increased intracranial pressure: comparison between mannitol and glycerol. Acta Neurochir (Wien) 1997; 139 (08) 725-732 , discussion 732–733
    PubMedSearch in Google Scholar
  • 20 Patil H, Gupta R. A comparative study of bolus dose of hypertonic saline, mannitol, and mannitol plus glycerol combination in patients with severe traumatic brain injury. World Neurosurg 2019; 125: e221-e228
    PubMedSearch in Google Scholar
  • 21 Rozet I, Tontisirin N, Muangman S. et al. Effect of equiosmolar solutions of mannitol versus hypertonic saline on intraoperative brain relaxation and electrolyte balance. Anesthesiology 2007; 107 (05) 697-704
    CrossrefPubMedSearch in Google Scholar
  • 22 Hassan ZU, Kruer JJ, Fuhrman TM. Electrolyte changes during craniotomy caused by administration of hypertonic mannitol. J Clin Anesth 2007; 19 (04) 307-309
    PubMedSearch in Google Scholar
  • 23 Hirota K, Hara T, Hosoi S, Sasaki Y, Hara Y, Adachi T. Two cases of hyperkalemia after administration of hypertonic mannitol during craniotomy. J Anesth 2005; 19 (01) 75-77
    PubMedSearch in Google Scholar
  • 24 Reinglass JL. Dose response curve of intravenous glycerol in the treatment of cerebral edema due to trauma. A case report. Neurology 1974; 24 (08) 743-747
    PubMedSearch in Google Scholar
  • 25 Meyer JS, Itoh Y, Okamoto S. et al. Circulatory and metabolic effects of glycerol infusion in patients with recent cerebral infarction. Circulation 1975; 51 (04) 701-712
    PubMedSearch in Google Scholar
  • 26 Sabharwal N, Rao GS, Ali Z, Radhakrishnan M. Hemodynamic changes after administration of mannitol measured by a noninvasive cardiac output monitor. J Neurosurg Anesthesiol 2009; 21 (03) 248-252
    CrossrefPubMedSearch in Google Scholar