Elsevier

World Neurosurgery

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

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

https://doi.org/10.1016/j.wneu.2016.04.021Get 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)

  • K. Hirota et al.

    Two cases of hyperkalemia after administration of hypertonic mannitol during craniotomy

    J Anesth

    (2005)
  • Cited by (0)

    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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