2017 Volume 29 Issue 2 Pages 20-24
Intracranial pressure (ICP) management is one of the most important issues for the treatment of severe traumatic brain injury (TBI). Hyperosmolar agent, such as mannitol, is commonly used for ICP management in TBI. However, decompressive procedures, either surgical and medical, may aggravate cerebral edema/swelling, induce remote intracranial hematomas, or enlarge initial hematomas. Hyperosmolar agents are recommended to use under ICP monitoring, although blind use of it is generally permitted in comatose patients with TBI. In this article, 3 cases with TBI are presented, whose initial intracranial hematomas have been enlarged after transfer between facilities, to worsen their neurological conditions, significantly. Before mannitol use, 1 of 3 cases were comatose, although the other 2 of 3 cases were alert and were not presented with worsening of neurological condition. In all of these 3 cases, mannitol was rapidly infused during transfer without ICP monitoring, suggesting hyperosmolar agents have potential to decrease ICP temporally to lose tamponade effect, leading to intracranial hematoma enlargement and neurological condition worsening. During a transfer between facilities, a certain situation when ICP monitoring cannot be achieved, and/or when emergency surgical procedure cannot be introduced, the use of hyperosmolar agents should be considered carefully.
