Life-Threatening Mannitol-Induced Hyperkalemia in Neurosurgical Patients

doi:10.1016/j.wneu.2016.04.021

World Neurosurgery

Volume 91, July 2016, Pages 672.e5-672.e9

https://doi.org/10.1016/j.wneu.2016.04.021 Get rights and content

Background

Mannitol is the most commonly used intraoperative hypertonic solution in patients undergoing craniotomy. However, its use has been reported to be associated with hyperkalemia, which can occasionally be life threatening.

Case Description and Literature Review

In this report, we discuss the case of a patient who had intraoperative cardiac arrest secondary to mannitol-induced hyperkalemia during a craniotomy for tumor resection. In addition, we provide a comprehensive review of the literature concerning similar cases previously reported, as well as a discussion of the pathophysiology of mannitol-induced hyperkalemia. Review of the literature suggests that patients prone to this phenomenon are young and healthy individuals with normal preoperative and postoperative cardiopulmonary and renal functions. The literature also suggests that the total dose of mannitol, as well as its rate of infusion, may play a role in the development of this phenomenon.

Conclusions

Knowledge of the existence of mannitol-induced hyperkalemia is paramount for the neurosurgeon and the anesthesiologist, because early treatment with insulin and calcium can quickly restore normal cardiac rhythm and prevent intraoperative death.

Introduction

Mannitol is the most commonly used intraoperative hypertonic solution in patients undergoing craniotomy.¹ It is used to reduce intracranial pressure and brain volume to facilitate resection of intracranial tumors and vascular malformations and to reduce the need for brain retraction during aneurysm clipping.2, 3, 4 However, mannitol use has been associated with potentially serious electrolyte abnormalities, most notably hyperkalemia.1, 3 In this report, we describe the case of a patient who had a serious complication of mannitol-induced hyperkalemia during a craniotomy for tumor resection. In addition, we provide a review of the literature concerning similar cases previously reported and a discussion of the pathophysiology of mannitol-induced hyperkalemia.

Section snippets

Case Report

A 43-year-old man with a history of adenocarcinoma of the sigmoid colon developed headaches. One week later, he underwent brain magnetic resonance imaging, which showed a right frontal metastatic tumor measuring 2.7 cm × 2.5 cm × 2.5 cm, with significant surrounding vasogenic edema and subfalcine herniation. The patient was placed on dexamethasone (6 mg every 6 hours) and levetiracetam (500 mg every 12 hours). Further workup did not show any evidence of adrenal metastases. Baseline laboratory

Discussion

The use of mannitol as a hypertonic agent for reduction of intracranial pressure was first described by Scharfetter et al. in 1960.⁵ It has since been used widely to decrease intracranial pressure and brain volume in patients undergoing intracranial surgery.1, 2, 3 Mannitol acts by shifting intracellular water molecules into the plasma, thus reducing intracranial pressure and brain volume and decreasing cerebral edema. However, the use of mannitol has been reported to be associated with

Conclusions

Mannitol-induced hyperkalemia during craniotomy is a rare and poorly understood phenomenon. The total dose of mannitol administered, as well as its rate of infusion, may play a role in the development of this condition. Patients undergoing mannitol infusion should undergo continuous intraoperative EKG monitoring. If EKG changes develop, mannitol infusion should be stopped immediately and the serum K⁺ level should be measured while resuscitation continues. Early recognition of this phenomenon

Acknowledgments

The authors thank Debra J. Zimmer for editorial assistance. The authors contributed as follows: conception/design, A.A.F.; data acquisition, analysis, and interpretation, all authors; drafting manuscript, A.A.F.; critical revision of manuscript, all authors; final approval of submitted version, all authors.

References (22)

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Electrolyte changes during craniotomy caused by administration of hypertonic mannitol
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The effect of high-dose mannitol on serum and urine electrolytes and osmolality in neurosurgical patients
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Two cases of hyperkalemia after administration of hypertonic mannitol during craniotomy

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(2005)

Cited by (19)

Sodium and Potassium Dysregulation in the Patient With Cancer
2022, Advances in Chronic Kidney Disease
Citation Excerpt :
Mannitol, by itself, can cause AKI through renal vasoconstriction and tubular vacuolization, but that has only been reported in patients receiving high repeated doses of mannitol. In contrast, electrolyte abnormalities with mannitol have been reported after a single dose.17,18 Once iso-osmolar or hyperosmolar hyponatremia is ruled out, the next step in assessing hypo-osmolar hyponatremia is evaluating antidiuretic hormone (ADH) activity.
Sodium and potassium disorders are pervasive in patients with cancer. The causes of these abnormalities are wide-ranging, are often primary or second-order consequences of the underlying cancer, and have prognostic implications. The approach to hyponatremia should focus on cancer-related etiologies, such as syndrome of inappropriate antidiuretic hormone, to the exclusion of other causes. Hypernatremia in non-iatrogenic forms is generally due to water loss rather than excessive sodium intake. Debilitated or dependent patients with cancer are particularly vulnerable to hypernatremia. Hypokalemia can occur in patients with cancer due to gastrointestinal disturbances, resulting from decreased intake or increased losses. Renal losses can occur as a result of excessive mineralocorticoid secretion or therapy-related nephrotoxicity. The approach to hyperkalemia should be informed by historical and laboratory clues, and pseudohyperkalemia is particularly common in patients with hematological cancers. Hyperkalemia can be seen in primary or metastatic disease that interrupts the adrenal axis. It can also develop as a consequence of immunotherapy, which can cause adrenalitis or hypophysitis. Tumor lysis syndrome (TLS) is defined by the development of hyperkalemia and is a medical emergency. Awareness of the electrolyte abnormalities that can befall patients with cancer is vital for its prompt recognition and management.
Hyperosmolar therapy
2021, Essentials of Evidence-Based Practice of Neuroanesthesia and Neurocritical Care
Hyperosmolar therapy is widely used in neuro-anesthesia and neurological intensive care.
In neurosurgical patients, hyperosmolar therapy is known to lower intracranial pressure (ICP) after traumatic brain injury and is associated with decreased mortality rate and is thus the gold standard for treatment of patients with elevated ICP.
Mannitol and hypertonic saline (HTS) are the most commonly used hyperosmotic/hyperosmolar agents in neurosurgical patients. These two agents have many similar mechanisms of action on the brain: predominantly, an increase in plasma osmotic pressure drawing water from the intracellular spaces with a subsequent decrease in volume of both edematous and normal brain tissue, and an improvement in blood rheology, both leading to a decrease in ICP and improvement of cerebral perfusion and oxygen delivery to the brain. Although the reduction in ICP has been consistently demonstrated with both mannitol and HTS, there is a suggestion that HTS provides a more robust and durable effect in lowering ICP than mannitol, provides more hemodynamic stability, and does not cause a rebound increase in ICP.
The choice of hyperosmolar agent should be guided by the nature of the disease, patient’s comorbidities, familiarity with the pharmacokinetic and pharmacodynamics of both agents, and awareness of their side effects. In neurocritical care, both mannitol and HTS are indicated for patients with neurologic deterioration and an increase of ICP higher than normal.
Future research examining the effect of hyperosmolar therapy on the delayed neurological outcome is warranted.
Anesthesia for Neurosurgical Emergencies
2020, Anesthesiology Clinics
Citation Excerpt :
If very high doses of mannitol are infused, or if the drug is given to patients with preexisting renal failure, mannitol is retained in the circulation. The ensuing increase in plasma osmolality results in the osmotic movement of water and potassium out of cells leading to extracellular fluid volume expansion (and possibly pulmonary edema), hyponatremia, metabolic acidosis (by dilution), and hyperkalemia6,7 Hypertonic saline
Intraoperative Mannitol Administration Increases the Risk of Postoperative Chronic Subdural Hemorrhage After Unruptured Aneurysm Surgery
2019, World Neurosurgery
Citation Excerpt :
However, for patients with unruptured aneurysms without brain swelling, there is no consensus about the intraoperative administration of mannitol.2,3,5,6,8,9 Although mannitol can facilitate brain retraction and enhance the cerebral blood flow by reducing the blood viscosity, it also can produce several adverse effects, including cardiac dysfunction, electrolyte imbalance, volume contraction with diuresis, and renal failure.3,4,10-18 Therefore, in such cases, mannitol mainly is administered according to the surgeon's preference and patient age.
Although mannitol is used widely to facilitate brain retraction in cases of ruptured aneurysms, there is no consensus about the intraoperative administration of mannitol in the case of unruptured aneurysms. Accordingly, this study was conducted to identify an intraoperative mannitol administration strategy.
Mannitol was administered routinely to patients (n = 90) from January 2015 to April 2016 and not administered to patients (n = 97) from May 2016 to June 2017. The patient groups with and without mannitol administration were then compared based on the patient medical records, radiologic data, and digital recordings from an intraoperative microscope.
The patient groups with and without mannitol administration were comparable regarding patient age, number of elderly patients, sex, and aneurysm locations. No between-group difference was identified in terms of the intradural procedural time, retraction-induced cortical injury, postoperative electrolyte imbalance, symptomatic infarction, and postoperative epidural hematomas. However, the patient group without mannitol administration showed a significantly lower incidence of chronic subdural hematomas (CSDHs) >50 mL (13.3% vs. 3.1%, P = 0.010). Moreover, a multivariate analysis revealed that an advanced age (P = 0.019), male sex (P <0.001), and mannitol administration (P = 0.040) were all statistically significant risk factors for a postoperative CSDH >50 mL following unruptured aneurysm surgery.
Withholding the administration of mannitol during a pterional or modified procedure for unruptured aneurysms was found to reduce the postoperative occurrence of a CSDH without increasing the operative difficulties or other postoperative complications.
Factors associated with an increased risk of perioperative cardiac arrest in emergent and elective craniotomy and spine surgery
2017, Clinical Neurology and Neurosurgery
Citation Excerpt :
One example is mannitol administration during neurosurgery used to aid in better visualization of the surgical field and to decrease intracranial pressure. It may also lead to derangements in fluid balance and electrolytes, especially hyperkalemia [15]. A relatively underappreciated component of cardiac arrest in the neurosurgical patient is the brain-heart connection.
Cardiac arrest following neurosurgery is a devastating complication associated with significant postoperative morbidity and mortality. There are no published studies that have used a large and robust multicenter database to specifically examine demographic and surgical risk factors associated with cardiac arrests following craniotomy and spine surgeries, respectively.
We retrospectively analyzed data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for the period between January 1, 2007 and December 31, 2013, focusing on cardiac arrest associated with craniotomy and spine surgery from the intraoperative period to 30 days after surgery. A total of 73,584 neurosurgical patients were analyzed (59,609 spine surgeries and 13,975 craniotomies).
There was an increased risk of cardiac arrest for both craniotomy and spine surgeries in patients with American Society of Anesthesiologists (ASA) Physical Status class 4 or 5, Black and Asian patients compared to White patients and patients totally dependent versus independent based on the ACS-NSQIP risk calculator. The risk of cardiac arrest for craniotomy was 66.5 per 10,000 anesthetics and for spine surgery was 21.3 per 10,000 anesthetics. Cardiac arrest associated with emergent non-traumatic craniotomy was 36.5% and with emergent non-traumatic spine surgery was only 17.3%. We found that 18% of cardiac arrests for craniotomy and 25% of cardiac arrests for spine surgery occurred from the intraoperative period through postoperative day (POD) 0. Both craniotomy and spine surgery patients who had a cardiac arrest were more likely to have acute kidney injury (AKI), failure to wean from the ventilator, postoperative dialysis, myocardial infarction (MI), venous thromboembolism (VTE) and sepsis in the postoperative period. The overall mortality rate for both craniotomy and spine surgeries who had a cardiac arrest from the intraoperative period to 30 days postoperative was 61.8% versus 1.2% in the no cardiac arrest control group.
Identification of patient and surgery specific characteristics from ACS-NSQIP data associated with cardiac arrest following craniotomy and spine surgery may lead to initiatives to reduce morbidity and mortality in the neurosurgical patient population.
Mannitol in kidney diseases: Does it have any role in current nephrology?
2024, Revista de Nefrologia, Dialisis y Trasplante

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: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Case ReportLife-Threatening Mannitol-Induced Hyperkalemia in Neurosurgical Patients

Background

Case Description and Literature Review

Conclusions

Introduction

Section snippets

Case Report

Discussion

Conclusions

Acknowledgments

J Clin Anesth

Kidney Int

Am Heart J

University of Miami Division of Clinical Pharmacology therapeutic rounds: drug-induced hyperkalemia

Am J Ther

Neurosurgical anesthesia

Fluid and electrolyte physiology

Surgical treatment of middle cerebral artery aneurysms

J Neurosurg

On osmotherapy in increased intracranial pressure

Schweiz Med Wochenschr

The effect of high-dose mannitol on serum and urine electrolytes and osmolality in neurosurgical patients

Can J Anaesth

Hyperkalemic cardiac arrest with hypertonic mannitol infusion: the strong ion difference revisited

Anesth Analg

Two cases of hyperkalemia after administration of hypertonic mannitol during craniotomy

J Anesth

Case Report
Life-Threatening Mannitol-Induced Hyperkalemia in Neurosurgical Patients