Mannitol

Pharmacologic Category

Diuretic, Osmotic; Genitourinary Irrigant

Dosing: Adult

Intracranial pressure (ICP), cerebral edema, reduction (off-label dosing): IV: 0.25 to 1 g/kg/dose; may repeat every 6 to 8 hours as needed (BTF [Carney 2016]; Grape 2012). Some suggest maintaining serum osmolality <320 mOsm/kg (Rabinstein 2006). However, this value is routinely exceeded without ill effect. A better marker for mannitol toxicity may be the serum osmol gap (or osmolal gap) and the target is <18 to 20 (Erstad 2016; García-Morales 2004).

Intraocular pressure (IOP), reduction: IV: 1.5 to 2 g/kg administered over 30 to 60 minutes 1 to 1.5 hours prior to surgery

IOP (traumatic hyphema), reduction: IV: 1.5 g/kg administered over 45 minutes twice daily for IOP >35 mm Hg; may administer every 8 hours in patients with extremely high pressure (Crouch 1999)

Kidney transplant:

Donor: 12.5 g (with adequate hydration) prior to nephrectomy; may repeat (Morris 2008)

Recipient: 50 g before kidney revascularization (Sprung 2000; Tiggeler 1984; van Valenberg 1987; Weimar 1983)

Transurethral irrigation: Use 5% urogenital solution as required for irrigation.

Dosing: Geriatric

Refer to adult dosing. Consider initiation at lower end of dosing range.

Dosing: Renal Impairment: Adult

Contraindicated in severe renal impairment. Use caution in patients with underlying renal disease. May be used to reduce the incidence of acute tubular necrosis when administered prior to revascularization during kidney transplantation.

Dosing: Hepatic Impairment: Adult

No dosage adjustment necessary.

Dosing: Pediatric

Note: The manufacturer's labeling recommends a test dose prior to starting IV mannitol therapy in patients with marked oliguria or suspected renal insufficiency.

Acute renal failure (oliguria): Infants, Children, and Adolescents: IV: Initial: 0.5 to 1 g/kg/dose infused over 2 to 6 hours; usual range: 0.25 to 2 g/kg/dose; may repeat dose every 4 to 6 hours; do not repeat dose if oliguria persists. Note: Although FDA-labeled indications, the use of mannitol for the prevention of acute renal failure and/or promotion of diuresis is not routinely recommended (Kellum 2008).

Test dose (to assess adequate renal function): IV: 0.2 g/kg (maximum dose: 12.5 g) over 3 to 5 minutes to produce a urine flow of at least 1 mL/kg/hour for 1 to 3 hours

Intracranial pressure (ICP), reduction: Infants, Children, and Adolescents: IV: Usual range: 0.25 to 1 g/kg/dose infused over 20 to 30 minutes; repeat as needed to maintain serum osmolality <300 to 320 mOsm/kg (BTF [Carney 2016]; Hegenbarth 2008; Kochanek 2012). Note: The manufacturer's labeling allows for higher single doses up to 2 g/kg/dose.

Intraocular pressure (IOP), reduction: Infants, Children, and Adolescents: IV: 1 to 2 g/kg/dose or 30 to 60 g/m²/dose infused over 30 to 60 minutes administered 1 to 1.5 hours prior to surgery

IOP (traumatic hyphema), reduction: Infants, Children, and Adolescents: IV: 1.5 g/kg/dose infused over 45 minutes twice daily for IOP >35 mm Hg; may administer every 8 hours in patients with extremely high pressure (Crouch 1999)

Dosing: Renal Impairment: Pediatric

Contraindicated in severe renal impairment. Use with caution in patients with underlying renal disease. May be used to reduce the incidence of acute tubular necrosis when administered prior to revascularization during kidney transplantation.

Dosing: Hepatic Impairment: Pediatric

No adjustment required.

Calculations

• Osmolal Gap
• Osmolal Gap (SI Units)

Use: Labeled Indications

Injection: Reduction of increased intracranial pressure (associated with cerebral edema and/or brain mass); reduction of increased intraocular pressure

Genitourinary irrigation solution: Irrigation in transurethral prostatic resection or other transurethral surgical procedures

Use: Off-Label: Adult

Improve renal transplant function

Clinical Practice Guidelines

Stroke:

AHA/ASA, “Guidelines for the Management of Spontaneous Intracerebral Hemorrhage,” July 2015

Traumatic Brain Injury:

"Guidelines for Field Management of Combat-Related Head Trauma," 2005

"Guidelines for Pre-Hospital Management of Severe Traumatic Brain Injury," March 2007

“Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents – 2nd Edition,” January 2012

“Guidelines for the Management of Severe Traumatic Brain Injury – 4^th edition,” September 2016

Administration: IV

Concentration and rate of administration depends on indication/severity or may be adjusted to urine flow. For cerebral edema or elevated intracranial pressure, administer over 30 to 60 minutes. Inspect for crystals prior to administration. If crystals present redissolve by warming solution. Do not place mannitol 25% injection in polyvinyl chloride (PVC) bags; a white flocculent precipitate may form from contact with PVC surfaces. Use filter-type administration set (≤5 micron) for infusion solutions containing mannitol ≥20% (WHO 2011). Do not administer with blood. Crenation and agglutination of red blood cells may occur if administered with whole blood.

Vesicant (at concentrations >5%); ensure proper catheter or needle position prior to and during IV infusion. Avoid extravasation of IV infusions. Administration into a large central vein is recommended.

Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave needle/cannula in place); gently aspirate extravasated solution (do NOT flush the line); initiate hyaluronidase antidote; remove needle/cannula; apply dry cold compresses (Hurst 2004; Reynolds 2014); elevate extremity.

Hyaluronidase: Intradermal or SubQ: Inject a total of 1 to 1.7 mL (15 units/mL) as five separate 0.2 to 0.3 mL injections (using a tuberculin syringe) into area of extravasation at the leading edge in a clockwise manner (Reynolds 2014) or SubQ: Administer multiple 0.5 to 1 mL injections of a 15 units/mL solution around the periphery of the extravasation (Kumar 2003).

Administration: Injectable Detail

pH: 4.5 to 7

Administration: Other

Irrigation: Administer using only the appropriate transurethral urologic instrumentation.

Administration: Pediatric

IV: Do not administer IM or SubQ. In-line filter set (≤5 micron) should always be used for mannitol infusion with concentrations ≥20% (WHO 2011); maximum concentration for administration: 25%. Inspect for crystals prior to administration; if crystals are present, redissolve by warming solution. Do not place mannitol 25% injection in PVC bags; a white flocculent precipitate may form from contact with PVC surfaces. Do not administer with blood; crenation and agglutination of red blood cells may occur. Infusion rate is dependent upon indication:

Acute renal failure: Administer over 2 to 6 hours.

Cerebral edema or increased intracranial pressure: Administer over 20 to 30 minutes.

Test dose (for oliguria): Administer over 3 to 5 minutes.

Vesicant (at concentrations >5%); ensure proper catheter or needle position prior to and during IV infusion. Avoid extravasation of IV infusions. If extravasation occurs, stop infusion immediately and disconnect (leave needle/cannula in place); gently aspirate extravasated solution (do NOT flush the line); initiate hyaluronidase antidote (see Management of Drug Extravasations for more details); remove needle/cannula; apply dry cold compresses (Hurst 2004); elevate extremity.

Vesicant/Extravasation Risk

Vesicant (at concentrations >5%)

Storage/Stability

Injection: Store at controlled room temperature; do not freeze. Crystallization of solution may occur at low temperatures; do not use solutions that contain crystals. To dissolve crystals in plastic containers, heat solution up to 60°C to 70°C (140°F to 158°F) (recommended temperature may vary; refer to manufacturer’s labeling), with agitation; do not immerse in water or microwave (may contaminate or damage product); allow solution to return to room or body temperature before use. To dissolve crystals in vials/bottles, warm vial in hot water at 80°C (176°F) and periodically shake vigorously or vial may be autoclaved at 121°C (250°F) for 20 minutes at 15 psi. Allow solution to return to room or body temperature before use.

Irrigation: Store at room temperature of 25°C (77°F); excursions permitted up to 40°C. Avoid excessive heat; do not warm above 150°F (66°C). Do not freeze.

Compatibility

See Trissel’s IV Compatibility Database

Open Trissel's IV Compatibility

Medication Patient Education with HCAHPS Considerations

What is this drug used for?

• It is used to get rid of extra fluid.

• It is used to treat brain swelling.

• It is used to lower high eye pressure.

• It is used to help get rid of unwanted substances in the body.

• It may be given to you for other reasons. Talk with the doctor.

Frequently reported side effects of this drug

• Headache

• Runny nose

• Nausea

• Vomiting

Other side effects of this drug: Talk with your doctor right away if you have any of these signs of:

• Kidney problems like unable to pass urine, blood in the urine, change in amount of urine passed, or weight gain.

• Fluid and electrolyte problems like mood changes, confusion, muscle pain or weakness, abnormal heartbeat, severe dizziness, passing out, fast heartbeat, increased thirst, seizures, loss of strength and energy, lack of appetite, unable to pass urine or change in amount of urine passed, dry mouth, dry eyes, or nausea or vomiting.

• Acidosis like confusion, fast breathing, fast heartbeat, abnormal heartbeat, severe abdominal pain, nausea, vomiting, fatigue, shortness of breath, or loss of strength and energy.

• Skin infection

• Shortness of breath

• Severe dizziness

• Passing out

• Excessive weight gain

• Swelling in the arms or legs

• Chest pain

• Fast heartbeat

• Blurred vision

• Vision changes

• Edema

• Chills

• Skin discoloration

• Injection site skin breakdown or irritation

• Signs of a significant reaction like wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat.

Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.

Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using this medicine.

Medication Safety Issues

Sound-alike/look-alike issues:

Contraindications

Injection: Hypersensitivity to mannitol or any component of the formulation; anuria; severe hypovolemia; active intracranial bleeding except during craniotomy; preexisting severe pulmonary vascular congestion or pulmonary edema.

Genitourinary irrigation solution: Anuria.

Warnings/Precautions

Concerns related to adverse effects:

• Extravasation: Vesicant (at concentrations >5%); ensure proper catheter or needle position prior to and during IV infusion. Avoid extravasation of IV infusions; may cause compartment syndrome. Administration into a large central vein is recommended.

• Fluid/electrolyte imbalance: May cause hypervolemia and electrolyte disturbances; monitor for new onset or worsening cardiac or pulmonary congestion. Also may cause profound diuresis with fluid and electrolyte loss; close medical supervision and dose evaluation are required. Correct electrolyte disturbances; adjust dose to avoid dehydration.

• Hypersensitivity: Serious hypersensitivity reactions (eg, anaphylaxis), including fatalities, have been reported. Discontinue mannitol immediately if hypersensitivity reaction develops and treat accordingly.

• Nephrotoxicity: May cause renal dysfunction especially with high doses; use caution in patients taking other nephrotoxic agents, with sepsis or preexisting renal disease. To minimize adverse renal effects, adjust to keep serum osmolality <320 mOsm/L. Discontinue if evidence of acute tubular necrosis.

Disease-related concerns:

• Cerebral edema: In patients being treated for cerebral edema, mannitol may accumulate in the brain (causing rebound increases in intracranial pressure) if circulating for long periods of time as with continuous infusion; intermittent boluses preferred. Cardiovascular status should also be evaluated; do not administer electrolyte-free mannitol solutions with blood. If hypotension occurs, monitor cerebral perfusion pressure to ensure adequate.

• CNS effects: CNS toxicity (eg, coma, confusion, lethargy) may occur; risk may be increased in patients with impaired renal function or with concomitant use of neurotoxic drugs. Discontinue mannitol if CNS toxicity develops.

• Renal impairment: Use with caution. In patients with severe impairment, do not use until adequacy of renal function and urine flow is established; use 1 to 2 test doses to assess renal response.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Warnings: Additional Pediatric Considerations

Mannitol may increase cerebral blood flow, increase the risk of postoperative bleeding in neurosurgical patients, and worsen intracranial hypertension in children who develop generalized cerebral hyperemia during the first 24 to 48 hours after traumatic brain injury.

Pregnancy Considerations

Mannitol crosses the placenta.

Outcome information following surgical use in pregnancy is limited; amniotic fluid volume may be decreased (Handlogten 2015; Kazemi 2014).

Breast-Feeding Considerations

It is not known if mannitol is present in breast milk.

According to the manufacturer, the decision to breastfeed during therapy should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and benefits of treatment to the mother. Other sources consider mannitol to be compatible with breastfeeding (WHO 2002).

Briggs' Drugs in Pregnancy & Lactation

• Mannitol

Adverse Reactions

Frequency not defined:

Cardiovascular: Cardiac failure, chest pain, edema, hypertension, localized phlebitis, palpitations, peripheral edema, tachycardia, thrombophlebitis

Central nervous system: Chills, coma, confusion, dizziness, headache, increased intracranial pressure (rebound), lethargy, malaise, pain, seizure

Dermatologic: Diaphoresis, localized erythema, localized rash, pruritus, skin necrosis, skin rash, urticaria

Endocrine & metabolic: Dehydration, fluid and electrolyte disturbance, hyperkalemia, hypernatremia, hypervolemia, hypokalemia, hyponatremia, hypovolemia, increased thirst, metabolic acidosis, metabolic alkalosis

Gastrointestinal: Nausea, vomiting, xerostomia

Genitourinary: Anuria, azotemia, diuresis, hematuria, oliguria, osmotic nephrosis, urinary retention

Hematologic & oncologic: Hemoconcentration

Local: Local inflammation, local pain, local pruritus

Neuromuscular & skeletal: Arm and/or wrist pain, asthenia, muscle rigidity, myalgia

Ophthalmic: Blurred vision

Renal: Polyuria

Respiratory: Cough, pulmonary congestion, pulmonary edema, rhinitis

Miscellaneous: Fever

Postmarketing: Acute renal failure, anaphylaxis, central nervous system toxicity, dyspnea, hypersensitivity reaction, hypotension

Allergy and Idiosyncratic Reactions

• Mannitol Allergy

Metabolism/Transport Effects

None known.

Drug Interactions Open Interactions

Amikacin (Oral Inhalation): May enhance the nephrotoxic effect of Mannitol (Systemic). Risk X: Avoid combination

Aminoglycosides: Mannitol (Systemic) may enhance the nephrotoxic effect of Aminoglycosides. Risk X: Avoid combination

Diacerein: May enhance the therapeutic effect of Diuretics. Specifically, the risk for dehydration or hypokalemia may be increased. Risk C: Monitor therapy

Opioid Agonists: May enhance the adverse/toxic effect of Diuretics. Opioid Agonists may diminish the therapeutic effect of Diuretics. Risk C: Monitor therapy

Sodium Phosphates: Diuretics may enhance the nephrotoxic effect of Sodium Phosphates. Specifically, the risk of acute phosphate nephropathy may be enhanced. Management: Consider avoiding this combination by temporarily suspending treatment with diuretics, or seeking alternatives to oral sodium phosphate bowel preparation. If the combination cannot be avoided, hydrate adequately and monitor fluid and renal status. Risk D: Consider therapy modification

Tobramycin (Oral Inhalation): Mannitol (Systemic) may enhance the nephrotoxic effect of Tobramycin (Oral Inhalation). Risk X: Avoid combination

Test Interactions

May cause false positive results for blood ethylene glycol concentrations. High mannitol concentrations may cause false low results for inorganic phosphorus blood concentrations if assay based on the conversion of phosphate (orthophosphate) to the phosphomolybdate complex is used.

Monitoring Parameters

Renal function, daily fluid I & O, serum electrolytes, serum and urine osmolality. Monitor infusion site.

For treatment of elevated intracranial pressure, some suggest maintaining serum osmolality <320 mOsm/kg due to the potential risk of acute renal tubular damage (Grape 2012; Rabenstein 2006). However, this value is routinely exceeded without ill effect. A better marker for mannitol toxicity may be the serum osmole gap and the target used by most clinicians is <18 to 20 (Erstad 2016; García-Morales 2004).

Advanced Practitioners Physical Assessment/Monitoring

Assess for adequate renal function and urine flow prior to administration. Infusion site must be closely monitored for extravasation; this is a vesicant. Renal and cardiovascular status should be monitored during infusion. Monitor for circulatory overload, CHF, rash, and water intoxication.

Nursing Physical Assessment/Monitoring

Adequate renal function should be present prior to administration. Monitor infusion site closely for extravasation; this is a vesicant. Monitor renal and cardiovascular status during infusion. Monitor for circulatory overload, CHF, rash, and water intoxication.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Solution, Intravenous:

Osmitrol: 5% (1000 mL); 10% (500 mL); 15% (500 mL); 20% (250 mL, 500 mL)

Generic: 20% (250 mL [DSC], 500 mL); 25% (50 mL)

Solution, Intravenous [preservative free]:

Generic: 20% (500 mL); 25% (50 mL [DSC])

Solution, Irrigation:

Resectisol: 5% (2000 mL)

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Intravenous:

Osmitrol: 10% (1000 mL); 20% (250 mL, 500 mL)

Generic: 20% (500 mL); 25% (50 mL)

Solution, Irrigation:

Resectisol: 5% (2000 mL, 4000 mL)

Anatomic Therapeutic Chemical (ATC) Classification

• B05BC01
• B05CX04

Generic Available (US)

Yes

Pricing: US

Solution (Mannitol Intravenous)

20% (per mL): $0.04 - $0.05

25% (per mL): $0.05 - $0.11

Solution (Osmitrol Intravenous)

5% (per mL): $0.05

10% (per mL): $0.11

15% (per mL): $0.12

20% (per mL): $0.21

Solution (Resectisol Irrigation)

5% (per mL): $0.01

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Mechanism of Action

Produces an osmotic diuresis by increasing the osmotic pressure of glomerular filtrate, which inhibits tubular reabsorption of water and electrolytes and increases urinary output . Mechanism of action in reduction of intracranial pressure (ICP) is less clear. However, it is thought that mannitol reduces ICP by reducing blood viscosity which transiently increases cerebral blood flow and oxygen transport and constricts pial arterioles. This in turn reduces cerebral blood volume and ICP. Furthermore, mannitol reduces ICP by withdrawing water from the brain parenchyma and excretes water in the urine (Allen 1998; BTF [Carney 2016]).

Pharmacodynamics/Kinetics

Onset of action: Diuresis: 1 to 3 hours; Reduction in intracranial pressure: ~15 to 30 minutes

Duration: Reduction in intracranial pressure: 1.5 to 6 hours

Distribution: 17 L; remains confined to extracellular space (except in extreme concentrations); does not penetrate the blood-brain barrier (generally, penetration is low)

Metabolism: Minimally hepatic to glycogen

Half-life elimination: 0.5 to 2.5 hours; 6 to 36 hours in renal failure

Excretion: Urine (~80% as unchanged drug)

Local Anesthetic/Vasoconstrictor Precautions

No information available to require special precautions

Effects on Dental Treatment

No significant effects or complications reported

Effects on Bleeding

No information available to require special precautions

Related Information

• Management of Drug Extravasations

Pharmacotherapy Pearls

Mannitol 20% has an approximate osmolarity of 1,100 mOsm/L and mannitol 25% has an approximate osmolarity of 1,375 mOsm/L

Index Terms

D-Mannitol

References

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Andreoli SP, "Acute Renal Failure in the Newborn," Semin Perinatol, 2004, 28(2):112-23.[PubMed 15200250]

Badjatia N, Carney N, Crocco TJ, et al, “Guideline for Prehospital Management of Traumatic Brain Injury 2nd Edition,” Prehosp Emerg Care, 2008, 12(Suppl 1):1-52.[PubMed 18203044]

Brain Trauma Foundation, "Guidelines for the Field Management of Combat-Related Head Trauma," 2005. Available at http://www.braintrauma.org

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Bratton SL, Chestnut RM, Ghajar J, et al, “Guidelines for the Management of Severe Traumatic Brain Injury. II. Hyperosmolar Therapy,” J Neurotrauma, 2007, 24(Suppl 1):14-20.[PubMed 17511539]

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García-Morales EJ, Cariappa R, Parvin CA, Scott MG, Diringer MN. Osmole gap in neurologic-neurosurgical intensive care unit: Its normal value, calculation, and relationship with mannitol serum concentrations. Crit Care Med. 2004;32(4):986-991.[PubMed 15071390]

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Kazemi P, Villar G, Flexman AM. Anesthetic management of neurosurgical procedures during pregnancy: a case series. J Neurosurg Anesthesiol. 2014;26(3):234-240.[PubMed 24296540]10.1097/ANA.0000000000000029

Kellum JA, Cerda J, Kaplan LJ, et al, “Fluids for Prevention and Management of Acute Kidney Injury,” Int J Art Organ, 2008, 31(2):96-110.[PubMed 18311727]

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Kochanek PM, Carney N, Adelson PD, et al, “Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents -- Second Edition,” Pediatr Crit Care Med, 2012, 13(Suppl 1):1-82.[PubMed 22217782]

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Mannitol injection [prescribing information]. Bethlehem, PA: B. Braun Medical Inc; September 2019.

Mannitol intravenous injection 25% [prescribing information]. Lake Forest, IL: Hospira, Inc; January 2019.

Miller RD, Fleisher LA, Wiener-Kronish JP, et al, eds, Miller’s Anesthesia, 7th ed, Philadelphia: Churchill Livingstone, 2009.

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Tiggeler RG, Berden JH, Hoitsma AJ, et al, "Prevention of Acute Tubular Necrosis in Cadaveric Kidney Transplantation by the Combined Use of Mannitol and Moderate Hydration," Ann Surg, 1985, 201(2):246-51.[PubMed 3918517]

van Valenberg PL, Hoitsma AJ, Tiggeler RG, et al, "Mannitol as an Indispensable Constituent of an Intraoperative Hydration Protocol for the Prevention of Acute Renal Failure After Renal Cadaveric Transplantation," Transplantation, 1987, 44(6):784-8.[PubMed 3122381]

Weimar W, Geerlings W, Bijnen AB, et al, "A Controlled Study on the Effect of Mannitol on Immediate Renal Function After Cadaver Donor Kidney Transplantation," Transplantation, 1983, 35(1):99-101.[PubMed 6401883]

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World Health Organization (WHO). Breastfeeding and maternal medication, recommendations for drugs in the eleventh WHO model list of essential drugs. 2002. Available at http://www.who.int/maternal_child_adolescent/documents/55732/en/.

Brand Names: International

Ardeaosmosol MA (CZ); Demanitol (PE); Demanitol AL (PY); Infusan M20 (ID); Isotol (IT); Mannisol (HU); Mannits (EE); Neurotol-M (IN); Osmitrol (AU, IN, NZ, SA, SG); Osmofundin (AT, ES, MY, RO, SG); Osmofundina (PT); Osmokab (MX); Osmorin (PE, PY); Osmosol (BD); Osmosteril (NL); Otsu-manitol (ID); Renitol (PH); Resectisol (TR); Rezosel (TR)

Last Updated 1/23/20