Department of Anesthesiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong.
School of Medicine, University of Connecticut, Farmington.
J Neurosurg Anesthesiol. 2019 Jul;31(3):273-284. doi: 10.1097/ANA.0000000000000520.
Despite clinical use spanning 50+ years, questions remain concerning the optimal use of mannitol. The published reviews with meta-analysis frequently focused on mannitol's effects on a specific physiological aspect such as intracranial pressure (ICP) in sometimes heterogeneous patient populations. A comprehensive review of mannitol's effects, as well as side effects, is needed.
The databases Medline (OvidSP), Embase (OvidSP), and NLM PubMed were systematically searched for randomized controlled trials (RCTs) comparing mannitol to a control therapy in either the critical care or perioperative setting. Meta-analysis was performed when feasible to examine mannitol's effects on outcomes, including ICP, cerebral perfusion pressure, mean arterial pressure (MAP), brain relaxation, fluid intake, urine output, and serum sodium. Systematic literature search was also performed to understand mannitol-related complications.
In total 55 RCTs were identified and 7 meta-analyses were performed. In traumatic brain injury, mannitol did not lead to significantly different MAP (SMD [95% confidence interval (CI)] =-3.3 [-7.9, 1.3] mm Hg; P=0.16) but caused significantly different serum sodium concentrations (SMD [95% CI]=-8.0 [-11.0, -4.9] mmol/L; P<0.00001) compared with hypertonic saline. In elective craniotomy, mannitol was less likely to lead to satisfactory brain relaxation (RR [95% CI]=0.89 [0.81, 0.98]; P=0.02), but was associated with increased fluid intake (SMD [95% CI]=0.67 [0.21, 1.13] L; P=0.004), increased urine output (SMD [95% CI]=485 [211, 759] mL; P=0.0005), decreased serum sodium concentration (SMD [95% CI]=-6.2 [-9.6, -2.9] mmol/L; P=0.0002), and a slightly higher MAP (SMD [95% CI]=3.3 [0.08, 6.5] mm Hg; P=0.04) compared with hypertonic saline. Mannitol could lead to complications in different organ systems, most often including hyponatremia, hyperkalemia, and acute kidney injury. These complications appeared dose dependent and had no long-term consequences.
Mannitol is effective in accomplishing short-term clinical goals, although hypertonic saline is associated with improved brain relaxation during craniotomy. Mannitol has a favorable safety profile although it can cause electrolyte abnormality and renal impairment. More research is needed to determine its impacts on long-term outcomes.
尽管甘露醇的临床应用已有 50 多年的历史，但关于其最佳使用方法仍存在一些问题。已发表的带有荟萃分析的综述经常侧重于甘露醇对特定生理方面的影响，例如颅内压（ICP），但这些研究的患者群体有时存在异质性。因此，我们需要对甘露醇的作用及其副作用进行全面的综述。
系统检索了 Medline（OvidSP）、Embase（OvidSP）和 NLM PubMed 数据库，以查找比较甘露醇与对照疗法在重症监护或围手术期的随机对照试验（RCT）。当可行时，进行荟萃分析以检查甘露醇对结局的影响，包括 ICP、脑灌注压、平均动脉压（MAP）、脑松弛、液体摄入、尿量和血清钠。还进行了系统文献检索以了解与甘露醇相关的并发症。
共确定了 55 项 RCT，并进行了 7 项荟萃分析。在创伤性脑损伤中，与高渗盐水相比，甘露醇并未导致 MAP 显著不同（SMD [95%置信区间（CI）]=-3.3 [-7.9, 1.3] mm Hg；P=0.16），但导致血清钠浓度显著不同（SMD [95% CI]=-8.0 [-11.0, -4.9] mmol/L；P<0.00001）。在择期开颅手术中，甘露醇不太可能导致令人满意的脑松弛（RR [95% CI]=0.89 [0.81, 0.98]；P=0.02），但与液体摄入增加相关（SMD [95% CI]=0.67 [0.21, 1.13] L；P=0.004）、尿量增加（SMD [95% CI]=485 [211, 759] mL；P=0.0005）、血清钠浓度降低（SMD [95% CI]=-6.2 [-9.6, -2.9] mmol/L；P=0.0002）和 MAP 略有升高（SMD [95% CI]=3.3 [0.08, 6.5] mm Hg；P=0.04）与高渗盐水相比。甘露醇可导致不同器官系统出现并发症，最常见的是低钠血症、高钾血症和急性肾损伤。这些并发症似乎与剂量有关，且无长期后果。
尽管高渗盐水在开颅手术期间与改善脑松弛有关，但甘露醇在实现短期临床目标方面是有效的。虽然甘露醇具有良好的安全性，但可引起电解质异常和肾功能损害。需要进一步研究以确定其对长期结局的影响。
