Osmotherapy

Hyperosmolar therapies have been used in the setting of neurocritical care patients since it was first discovered that, while the total volume of the intracranial compartment is constant, shifts in the composition of the contents can occur; this has been termed the Monro-Kellie doctrine. Mannitol and hypertonic saline have been studied in this context since the early 1900s when this hypothesis was put forward. Despite this theory being over a century old, there is a lack of guideline-based recommendations for use in the setting of intracranial hypertension and cerebral edema. However, there is a significant literature available noting osmotherapy use in the setting of intracranial hypertension and cerebral edema. Additionally, there are multiple formulations and dosing strategies that require further analysis. The purpose of this chapter is to provide a list of osmotherapy agents, describe the chemical composition of these agents, evaluate the pertinence of use in neurocritical care, review the pharmacology and pharmacokinetic profile, evaluate available literature, and emphasize important safety points. Additional randomized control trials are warranted in order to improve guideline-based recommendations and standardization of care.