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I'm more from the adult world and only use Mannitol if I use anything.  I make my decision partly using point-of-care ultrasound.  I use Mannitol only if the IVC does not show evidence of hypovolemia.  If there's evidence of hypovolemia I avoid mannitol with the thinking that the cerebral blood flow will benefit more from IV fluids.  I also won't usually give mannitol if there is no evidence of raised ICP based on measurement of the optic nerve shadow.  I'm not sure though what normal optic nerve diameter would be based on age.  Does anyone know if there is data in the peds literature for the optic nerve?
Steve Socransky
Sudbury, Ontario

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On 2013-02-21, at 12:35 PM, Daniel Thimann <[log in to unmask]> wrote:

> 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. 
> 
> Thank you 
> 
> Daniel Thimann MD PGY-5
> Pediatric Emergency Medicine Fellow 
> 
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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> 

For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
                 http://listserv.brown.edu/ped-em-l.html