Mannitol parenteral
- Drugs List
- Therapeutic Indications
- Dosage
- Administration
- Contraindications
- Precautions and Warnings
- Pregnancy and Lactation
- Side Effects
- Monograph
Presentation
Infusions of mannitol.
Drugs List
Therapeutic Indications
Uses
Acute renal failure (oliguric phase): prophylaxis/treatment
Forced diuresis for increased excretion of toxic substances
Osmotic diuresis
Reduction of intracranial pressure
Treatment of cerebral oedema
Urgent and/or pre-operative reduction of elevated intraocular pressure
Dosage
Adults
Acute renal failure
Between 50g to 200g in a 24 hour period may be given. An adequate response is usually observed with approximately 100g per 24 hours.
Maximum single dose: 50g.
Maximum daily dose: 200g.
The rate of infusion is usually adjusted to maintain a urine flow of at least 30ml/hour to 50ml/hour. Only in emergency situations, the maximum infusion rate can be as high as 200mg/kg infused over 5 minutes. After 5 minutes, the infusion rate should be readjusted to maintain a urine flow of 30ml/hour to 50ml/hour, with a maximum dose of 200g/24 hours.
Use in patients with marked oliguria or suspected inadequate renal function
Test dose: Approximately 200mg/kg over a period of 3 to 5 minutes. The response to the test dose is considered adequate if at least 30ml/hour to 50ml/hour of urine is excreted for 2 to 3 hours.
If adequate response is not attained, a further test dose may be given. If an adequate response to the second test dose is not attained, treatment with mannitol should be discontinued and the patient reassessed as established renal failure may be present.
Reduction of intracranial pressure, cerebral volume and intraocular pressure
1.5g/kg to 2g/kg, given over a period of 30 to 60 minutes.
If mannitol is being given as a preoperative treatment the dose should be administered 1 to 1.5 hours prior to surgery, to obtain the maximum effect.
The following alternative dosing schedule may be suitable:
0.25g/kg to 2g/kg. This dose may be repeated once or twice, after an interval of 4 to 8 hours, if necessary.
Renal failure prophylaxis
50g to 100g, given during cardiovascular and other types of surgery to help prevent acute renal failure. The concentration and volume will depend on the fluid requirements of the patient.
Promotion of elimination of renally excreted toxic substances in poisoning
Initial loading dose: 25g.
In induction of forced diuresis in the adjunctive treatment of severe drug intoxications, the dose of mannitol should be adjusted to maintain urinary output of at least 100ml/hour and positive fluid balance of 1 to 2 litres.
Children
In renal insufficiency
Test dose: 200mg/kg over 3 to 5 minutes.
Treatment dose: 0.5g/kg to 1.5g/kg. This dose may be repeated once or twice, after an interval of 4 to 8 hours, if necessary. Reduction of cerebral oedema, intracranial pressure and intraocular pressure
Treatment dose: 0.5g/kg to 1.5g/kg, to be given over 30 to 60 minutes. This dose may be repeated once or twice, after an interval of 4 to 8 hours, if necessary.
The following alternative dosing schedule may be suitable:
Peripheral oedema and ascites (unlicensed)
1g/kg to 2g/kg, given over 2 to 6 hours.
Cerebral oedema (unlicensed)
Children aged 12 to 18 years
0.25g/kg to 2g/kg, by intravenous infusion over 30 to 60 minutes. This dose may be repeated once or twice, after an interval of 4 to 8 hours, if necessary.
Children aged 1 month to 12 years
0.25g/kg to 1.5g/kg, by intravenous infusion over 30 to 60 minutes. This dose may be repeated once or twice, after an interval of 4 to 8 hours, if necessary.
Patients with Renal Impairment
Patients should be give a test dose prior to treatment as they are more susceptible to adverse events (See Dosage; Adult).
Administration
For intravenous infusion only.
Contraindications
No response to test dose
Pulmonary oedema
Renal failure with anuria
Severe cardiac failure
Severe dehydration
Precautions and Warnings
Elderly
Predisposition to hypovolaemia
Breastfeeding
Cardiac impairment
Hyponatraemia
Intracranial haemorrhage
Pregnancy
Severe renal impairment
May obscure/intensify inadequate hydration
Evaluate patients for cardiovascular disease prior to treatment
Avoid rapid infusion rates
Do not mix with whole blood
Examine solution for crystals before use- redissolve if necessary
High doses in large volumes may cause water intoxication/hyponatraemia
If extravasation occurs follow local policy & seek expert help immediately
Perform test dose to determine adequate response
May aggravate pre-existing haemoconcentration
Monitor cardiac function
Monitor central venous pressure
Monitor fluid and electrolyte status
Monitor pulmonary function regularly
Monitor renal function
Monitor serum osmolarity
Monitor urine output
May exacerbate existing or latent congestive cardiac failure
May affect results of some laboratory tests
Discontinue if hypersensitivity reactions occur
Discontinue in the event of progressive cardiac failure
Discontinue in the event of progressive deterioration in pulmonary function
Discontinue in the event of progressive renal damage
Mannitol solution may crystallise during storage. Storing the solution between 20 and 30 degrees C helps prevent this. However carefully examine solution for crystals immediately before use. Crystals can be redissolved by raising the temperature to 60 degrees C and shaking occasionally. Cool to blood temperature before use.
Mannitol may open the blood-brain barrier at high doses, resulting in a rebound increase in intracranial pressure.
Mannitol is not recommended in intracranial bleeding except during craniotomy.
Pregnancy and Lactation
Pregnancy
Use mannitol with caution during pregnancy.
There is extremely limited information about its use in pregnancy. Schaefer (2007) states that if an osmotic diuretic is required during pregnancy mannitol may be used, although diuretics are not part of the standard therapy for hypertension and oedema in pregnancy. Schaefer concludes that exposure to a diuretic is not an indication for interrupting the pregnancy.
The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).
Lactation
Use mannitol with caution during breastfeeding.
It is unknown if mannitol is excreted into human breast milk. Although there is no hard data, drawing on knowledge of mannitol and mother and infant physiology, one author suggests that passage into the milk is only likely in the first few days post partum, and considers passage into the breast milk likely to be minimal beyond 48 hours post-partum. Further, that oral absorption by the infant is likely to be minimal after the first few days post partum (when the gastrointestinal tract becomes less porous). Watery diarrhoea in the infant is a remote possibility. A reduction in the production of milk, from the osmotic diuretic effect is possible (Hale, 2010).
Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1
Side Effects
Acidosis
Acute renal failure
Anaphylactic reaction
Anaphylactic shock
Anuria
Arm pain
Arrhythmias
Asthenia
Azotaemia
Blurred vision
Chest pain
Chills
Circulatory disturbances
Coma
Compartment syndrome
Confusion
Congestive cardiac failure
Convulsions
Cramp
Dehydration
Diarrhoea
Diuresis
Dizziness
Dry mouth
Erythema at injection site
Fever
Fluid and electrolyte disturbances
Haematuria
Headache
Hypersensitivity reactions
Hypertension
Hyponatraemia
Hypotension
Inflammation (injection site)
Itching (injection site)
Lethargy
Local pain (injection site)
Malaise
Nausea
Oedema
Oliguria
Osmotic nephrosis
Palpitations
Polyuria
Pulmonary oedema
Raised intracranial pressure
Rash at injection site
Respiratory depression
Rhinitis
Skin necrosis
Tachycardia
Thirst
Thrombophlebitis
Thrombophlebitis (injection site)
Urinary retention
Urticaria
Vomiting
Effects on Laboratory Tests
Mannitol can cause false low results in some tests systems for inorganic phosphorus blood concentrations.
Mannitol produces false positive results in tests for blood ethylene glycol concentrations in which mannitol is initially oxidized to an aldehyde.
Overdosage
It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.
The following number will direct the caller to the relevant local centre (0844) 892 0111
Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).
Further Information
Last Full Review Date: November 2014
Reference Sources
Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 2nd edition (2007) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.
Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 9th edition (2011) ed. Briggs, G., Freeman, R. and Yaffe, S. Lippincott Williams & Wilkins, Philadelphia.
Martindale: The Complete Drug Reference, 37th edition (2011) ed. Sweetman, S. Pharmaceutical Press, London.
Medications and Mothers' Milk, 14th Edition (2010) Hale, T. Hale Publishing, Amarillo, Texas.
Summary of Product Characteristics: Mannitol 10% solution for infusion. Fresenius Kabi Ltd. Revised November 2014.
Summary of Product Characteristics: Mannitol 20% solution for infusion. Fresenius Kabi Ltd. Revised November 2014.
Summary of Product Characteristics: Mannitol 10% solution for infusion BP. Baxter Healthcare Ltd. Revised August 2012.
Summary of Product Characteristics: Mannitol 15% solution for infusion. Baxter Healthcare Ltd. Revised January 2018.
Summary of Product Characteristics: Mannitol intravenous infusion 20% w/v from Baxter Healthcare Ltd. Revised January 1996.
NICE Evidence Services Available at: www.nice.org.uk Last accessed: 23 November 2017
Medscape UK | Univadis prescription drug monographs & interactions are based on FDB Multilex Content
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