Mannitol & vascular surgery

[dhb]

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Do you give mannitol prior to Ao cross clamp for renal protection?
Surgeon asked me today and i said i wouldn't recommend it, but there is some litterature on the subject although nothing definitive...

 

[nap$ter]

Do you give mannitol prior to Ao cross clamp for renal protection?
Surgeon asked me today and i said i wouldn't recommend it, but there is some litterature on the subject although nothing definitive...

i give it if the surgeon wants it. it's not a subject worthy of discussion during an aortic case.

data is inconclusive (there are a ton of studies), and it is probably relatively harmless.

blade could probably elaborate with a fountain of studies...

 

[BLADEMDA]

The use of mannitol as a protective agent during renal transplantation stems from its ability to increase renal blood flow. This is thought to be due to the release of intrarenal vasodilating prostaglandins and atrial natriuretic peptide (ANP). A second perceived benefit of mannitol is related to its role as an oxygen free-radical scavenger that may impart some protection to the kidney following reperfusion of the renal allograft. Finally, when administered early in the course of acute renal failure (ARF), mannitol tends to flush out cellular debris and prevent tubular cast formation. These actions may convert a patient from oliguric ARF to nonoliguric ARF. A randomized study of hydration with mannitol vs. hydration without mannitol in cadaveric renal transplant demonstrated a significant reduction in postoperative acute tubular necrosis in patients treated with mannitol. However, 3 months after transplantation no difference was found in kidney function. The commonly used dose of mannitol for renal protection is 12.5 to 25 grams. It has become common practice to give mannitol, as well as adequate volume expansion with crystalloid prior to vessel clamp in order to decrease postoperative ATN. The studies cited are all limited, i.e. retrospective, single-center, and/or small number of patients.

http://www.openanesthesia.org/ABA:Renal_transplant_-_mannitol

 

[Planktonmd]

It's an old and mostly harmless intervention that could theoretically have some benefit, so I wouldn't mind doing it if it makes the surgerizer happy!

 

[drmwvr]

Fast surgeons are better than mannitol, so at my practice the only people who bring up the topic are folks new from training programs.

 

[fakin' the funk]

Do you give mannitol prior to Ao cross clamp for renal protection?
Surgeon asked me today and i said i wouldn't recommend it, but there is some litterature on the subject although nothing definitive...

Low risk at those dose ranges (12.5-25g), potential benefit.

 

[BLADEMDA]

I use 12.5 mg of Mannitol routinely on these cases. I'm old school and there may be some benefit to it.

 

[jwk]

Fast surgeons are better than mannitol, so at my practice the only people who bring up the topic are folks new from training programs.

We only give it if the surgeon asks for it. The better ones don't. The ones that take all day for endo AAAs do.

 

[dhb]

The problem is that even if it's low risk it interferes with urine output and volume status assessment : once they start peeing water you loose track a little

 

[Femtochemistry]

do it. cheap. little to no s/e. may have benefit. happy surgeon/crna as they feel they are "doing something."

 

[BuzzPhreed]

I'm not sure this is evidenced based (yeah, I saw Blade's link). Doesn't mean it's evidence based.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3377490/

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0085029

 

[BLADEMDA]

ABA:Renal transplant - mannitol



The use of mannitol as a protective agent during renal transplantation stems from its ability to increase renal blood flow. This is thought to be due to the release of intrarenal vasodilating prostaglandins and atrial natriuretic peptide (ANP



Sources
PubMed


R Lauzurica, J Teixidó, A Serra, P Torguet, J Bonet, J Bonal, M Borrás, R Romero, A Caralps
Hydration and mannitol reduce the need for dialysis in cadaveric kidney transplant recipients treated with CyA.
Transplant. Proc.: 1992, 24(1);46-7
[PubMed:1539337] [WorldCat.org] (P p)



I Porras, J M Gonzalez-Posada, M Losada, A Jordano, V Lorenzo, F Gonzalez-Miranda, F Santolaria, A Torres
A multivariate analysis of the risk factors for posttransplant renal failure: beneficial effect of a flush solution with mannitol.
Transplant. Proc.: 1992, 24(1);52-3
[PubMed:1539340] [WorldCat.org] (P p)



K F Richards, L P Belnap, W V Rees, L E Stevens
Mannitol reduces ATN in cadaveric allografts.
Transplant. Proc.: 1989, 21(1 Pt 2);1228-9
[PubMed:2496491] [WorldCat.org] (P p)



R G Tiggeler, J H Berden, A J Hoitsma, R A Koene
Prevention of acute tubular necrosis in cadaveric kidney transplantation by the combined use of mannitol and moderate hydration.
Ann. Surg.: 1985, 201(2);246-51
[PubMed:3918517] [WorldCat.org] (P p)



P L van Valenberg, A J Hoitsma, R G Tiggeler, J H Berden, H J van Lier, R A Koene
Mannitol as an indispensable constituent of an intraoperative hydration protocol for the prevention of acute renal failure after renal cadaveric transplantation.
Transplantation: 1987, 44(6);784-8
[PubMed:3122381] [WorldCat.org] (P p)


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[BuzzPhreed]

Conclusions
Intravascular administration of mannitol does not convey additional beneficial effects beyond adequate hydration in the patients at increased risk of AKI. For contrast-induced nephropathy, the use of mannitol is even detrimental. Further research evaluating the efficiency of mannitol infusions in the recipients of renal allograft should be undertaken.

Published: January 14, 2014

 

[BLADEMDA]

Conclusions
Intravascular administration of mannitol does not convey additional beneficial effects beyond adequate hydration in the patients at increased risk of AKI. For contrast-induced nephropathy, the use of mannitol is even detrimental. Further research evaluating the efficiency of mannitol infusions in the recipients of renal allograft should be undertaken.

Published: January 14, 2014

Mannitol has some peer reviewed evidence behind it. Yes, it is controversial and many don't use it. But, like many things we do there are some studies showing benefit and some showing no benefit. By no means am I convinced of its effectiveness but with adequate hydration (that's the key) it may be beneficial in certain situations.

 

[BLADEMDA]

Do you give mannitol prior to Ao cross clamp for renal protection?
Surgeon asked me today and i said i wouldn't recommend it, but there is some litterature on the subject although nothing definitive...

Br J Surg. 1996 Sep;83(9):1230-3.
Randomized controlled trial of the effect of mannitol on renalreperfusion injury during aortic aneurysm surgery.
Nicholson ML1, Baker DM, Hopkinson BR, Wenham PW.
Author information

Abstract
The effects of mannitol on renal impairment following infrarenal aortic aneurysm repair were studied. Patients received either mannitol 0.3 g/kg (n = 15) or saline (n = 13) as a rapid intravenous infusion before aortic cross-clamping. One patient in the control group developed fatal postoperative renal failure but there was no renal failure in the mannitol group. Two patients treated with mannitol died from perioperative myocardial infarction. There were no significant differences in postoperative blood urea level, serum creatinine concentration or creatinine clearance between mannitol and control groups. In patients who had mannitol there was a significant diuresis on the first day after operation (mean urine output 2250 ml) compared with before operation (1557 ml) (P = 0.007). Compared with controls, patients treated with mannitol had lower mean (s.e.m.) postoperative levels of urinary albumin (160(32) versus 500(140) mg per mmol creatinine; P = 0.036) and N-acetyl glucosaminidase (143(34) versus 271(70) mumol per mmol creatinine; P = 0.04) indicating a reduced level of subclinical glomerular and renal tubular damage. These data demonstrate that mannitol reduces subclinical renal injury following infrarenal aortic aneurysm repair.

 

[BLADEMDA]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3580749/

Mannitol increases renal blood flow and maintains filtration fraction and oxygenation in postoperative acute kidney injury: a prospective interventional study
Gudrun Bragadottir, Bengt Redfors, and Sven-Erik Ricksten

 

[BLADEMDA]

We only give it if the surgeon asks for it. The better ones don't. The ones that take all day for endo AAAs do.

We agree here. What matters most are clamp time and adequate hydration. Mannitol is a poor substitute for surgical skill.

In an open AAA there is literally a cross clamp.

For emergency endovascular AAA the balloon acts a cross clamp.

 

[BLADEMDA]

Is anyone using bicarbonate or N acetylcysteine for patients at risk of AKI following an endoovascular AAA?

https://www.hosp.uky.edu/pharmacy/formulary/criteria/ContrastNephropathyGuidelines.pdf

 

[BuzzPhreed]

Mannitol, loop diuretics, and dopamine are used clinically in an attempt to preserve renal function during aortic surgery. Significant controversy exists regarding the use of these agents as well as the mechanisms by which they may offer a protective effect. Despite studies demonstrating little or no benefit,[247] [248] [249] [250] it is widely believed that renal protection before aortic cross-clamping is beneficial and therefore many clinicians administer these drugs.

http://www.noranaes.org/logbook/res...sthesia 6th Ed/das/book/body/0/1255/1539.html

In other words, it's f***ing voodoo.