I am also interested in this topic since I do not believe there is a standard of care. There new guidelines, ie revision to the previous guidelines for traumatic brain injury in pediatrics also reflects the same fact towards preference of 3% saline in a dose of 6-10 ml/kg over mannitol. Mannitol could be associated with hypotension secondary to increase in urine output and hypotension is not favored in TBI. Also, if disruption of the Blood brain barrier occurs, there is a theoretical risk that mannitol could leach out to brain or the brain bleed and increase the osmotic pressure inside the brain leading to worsening cerebral edema.
I have also read that in some papers mannitol may have increase morbidity and worse outcomes. These guidelines are pretty extensive if you have time to read them. I as a fellow do prefer 3% saline over mannitol, in our institution we currently use a dose of 3-5 ml/kg and we usually infuse it over 15 minutes unless it is a critical case we push it. It may be interesting to know what other doses people use and how they use it.
Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition.
Pediatr Crit Care Med. 2012 Mar;13(2):252.
Daniel Thimann MD PGY-5
Pediatric Emergency Medicine Fellow
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