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Tier 2 therapy

Diuretics

Intracranial pressure can be aggressively addressed with the administration of osmotic diuretics. Osmotic diuretics such as mannitol should not be given to any patient without being certain that the patient has been volume resuscitated. If not, their use can precipitate acute renal failure. For this reason they are reserved as tier 2 therapies.

Mannitol improves cerebral blood flow and reduces intracranial pressure by decreasing oedema. After administration, mannitol expands the plasma volume and reduces blood viscosity, which improves cerebral blood flow and delivery of oxygen to the brain. Additionally, mannitol assists in scavenging free radicals, which contribute to secondary injury processes. Vasoconstriction occurs as a sequela to the increased partial pressure of oxygen leading to an immediate decrease in ICP.

Additionally, the osmotic effect of mannitol reduces extracellular fluid volume within the brain. Mannitol (0.5-2.0 g/kg) should be given as a bolus over 15 minutes to optimize the plasma expanding effect. Continuous infusions of mannitol increase the permeability of the blood brain barrier exacerbating oedema. Lower doses of mannitol are as effective at decreasing ICP as higher doses, but may not last as long. Currently, there is no evidence to support that mannitol is contraindicated in the presence of intracranial haemorrhage as has been suggested.

Mannitol reduces brain oedema [...]

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