Case ReportLife-Threatening Mannitol-Induced Hyperkalemia in Neurosurgical Patients
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.
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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.