Mannitol di IGD

Rekomendasi : penggunaan mannitol

sebelum dilakukan pemasangan ICP
monitoring bisa dilakukan pada pasien
yang sudah teresusitasi
 Klinis tekanan tinggi intrakranial
• Dilatasi pupil (unilateral /bilateral)
• Reflrek pupil terhadap cahaya : asimetrik
• Postur dekortikasi / deserebrasi (biasa
kontralateral dari pupil yang “fix & dilated”)

• Perburukan neurologis progresif yang bukan

diakibatkan faktor ekstrakranial
  Tanda efek massa
• Defisit neurologis fokal misalnya hemiparese

Perburukan mendadak sebelum

dilakukan penunjang CT kepala

Setelah CT kepala, didapatkan lesi yang

berhubungan dengan peningkatan ICP
 Perjalanan menuju OK setelah CT

Untuk penilaian “salvageability”

• Pada pasien dengan pemeriksaan fisik tidak
didapatkan fungsi brainstem, diberikan
mannitol untuk melihat ada tidak kembalinya
reflek batang otak
 Mannitol di IGD

 Diberikan BOLUS 0.25 – 1 gram / kg BB

dalam waktu < 20 menit

 “follow up dosing”
 Pengulangan dosis
• Diperlukan reduksi ICP urgent, dosis inisial 1
gram / kgBB dalam 30 menit

• Ketika diharapkan efek reduksi ICP longterm,

infusion time diperpanjang menjadi 60 menit
dan dosisnya dikurangi menjadi 0.25 – 0.5
gram / kgBB per 6 jam
• There is no strong evidence-based argument for the implementation of bolus
osmotherapy in the pre-hospital or ED settings for patients who sustain a TBI.
• If osmotherapy is to be implemented, there are no definitive answers concerning
which osmotic agent is the most ideal and which has the strongest evidence base.
• Other unanswered questions concern how frequently a patient can be re-dosed,
whether osmotic agents can be safely interchanged for the same patient and when
clinicians should stop osmotherapy.
 Syarat pemberian

As a routine,
• Boluses of 100‑200 ml over 4‑6th
hourly intervals especially when ICP monitoring is
not routinely practiced.

• Mannitol needs to be stopped when serum

osmolality exceeds 320 mOsm/l, or the osmolality
gap exceeds >20 mOsm/l.
Durasi pemberian

Mannitol boluses are generally effective

for 48 to 72 hours.

Its routine/scheduled use beyond 72

hour can become ineffective  even
with an intact blood-brain barrier it
will slowly leak into the interstitial fluid
/ brain parenchyma.
Pemberhentian pemberian
• Mannitol should not be used for more than 8 days.
Tan, Ge & Zhou, Ji-Ying & Mao, Yuan-Chao & Liu, Bo-Wen & Liao, Qi. (2008). Most effective daily dose and use method of
mannitol in patients with cerebral hemorrhage at acute stage. Zhonghua yi xue za zhi. 88. 889-91.

• If the patient receives more than 200 gm of mannitol

without benefit, mannitol use should be
discontinued
Tenny S, Patel R, Thorell W. Mannitol. [Updated 2022 Feb 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;
2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470392/

• If a beneficial effect (urine production of 1 to 3

mL/min) is not seen within 1 hour, mannitol infusion
is discontinued
Chew, Dennis J. (2006). Fluid, Electrolyte, and Acid-Base Disorders in Small Animal Practice || Fluid Therapy During Intrinsic Renal
Failure. , (), 518–540. doi:10.1016/b0-72-163949-6/50025-4
Kapan memberhentikan
• Approximately after 60 to 72 hrs : slow accumulation
of mannitol in the cerebrospinal fluid.
• If cerebrospinal fluid osmolarity increases
significantly, mannitol dosage should be decreased or
the treatment discontinued.
• If significant increases in cerebrospinal fluid
osmolarity have already developed, mannitol dosage
should be reduced very slowly to prevent rebound
effects
Polderman, K. H.; van de Kraats, G.; Dixon, J. M.; Vandertop, W. P.; Girbes, A. R. J. (2003). Increases in spinal fluid osmolarity
induced by mannitol. Critical Care Medicine, 31(2), 584–590. doi:10.1097/01.ccm.0000050287.68977.84
Cara tapering
Taper over about 3-4 days
• First, stop the furosemide order.
• The next day, decrease the frequency of the mannitol
(from q6h to q8h or from q8h to q12h).
• The next day, decrease the dose to 0.3 grams per kg.
• The next day decrease the dose to 0.15 gram per kg.
• The next day, stop the mannitol order.
http://neurocriticalcare.pbworks.com/w/page/33454341/Mannitol%20Rx
 Urgent Longterm TTIK
TTIK
20 gram
Berat Dosis mannitol
badan dalam 100 cc
cairan
1 gram 0.5 gram 0.25 gram

30 kg 150 75 37.5
40 kg 200 100 50
50 kg 250 125 62.5
60 kg 300 150 75
70 kg 350 175 87.5
CC
80 kg 400 200 100
90 kg 450 225 112.5