Can Mannitol (Intravenous Fertilization) be administered in a hypertensive crisis?

From the Guidelines

Mannitol should be avoided in hypertensive crisis as it can worsen hypertension by expanding intravascular volume. The primary goal in managing hypertensive crisis is to reduce blood pressure in a controlled manner to prevent target organ damage. According to the 2019 ESC Council on Hypertension position document on the management of hypertensive emergencies 1, patients with hypertensive emergencies should be treated with intravenous blood pressure-lowering agents to reach the recommended blood pressure target in the designated time-frame.

The use of mannitol, an osmotic diuretic, is not recommended in this context as it can increase intravascular volume and potentially exacerbate hypertension. Instead, first-line treatments for hypertensive crisis typically include intravenous antihypertensives such as:

• Labetalol (initial dose 20mg IV, followed by 20-80mg every 10 minutes as needed)
• Nicardipine (initial rate 5mg/hr, titrated by 2.5mg/hr every 5-15 minutes, maximum 15mg/hr)
• Clevidipine (starting at 1-2mg/hr, doubling every 90 seconds until near target BP) 1.

If a patient in hypertensive crisis also has increased intracranial pressure requiring osmotic therapy, the management becomes more complex and requires careful balancing of blood pressure control while addressing cerebral edema, preferably in an ICU setting with neurological and cardiovascular monitoring. The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1 also emphasizes the importance of rapid recognition and early initiation of appropriate antihypertensive treatment in patients with hypertensive emergencies.

From the FDA Drug Label

The dosage, concentration and rate of administration depend on the age, weight and condition of the patient.

CONTRAINDICATIONS Well established anuria due to severe renal disease. ( 4) Severe pulmonary congestion or frank pulmonary edema. ( 4) Active intracranial bleeding except during craniotomy ( 4) Severe dehydration. ( 4) Progressive heart failure or pulmonary congestion after institution of mannitol therapy. ( 4)

WARNINGS AND PRECAUTIONS Fluid and Electrolyte Imbalances: Mannitol administration may obscure and intensify inadequate hydration or hypovolemia. Accumulation of mannitol may intensify existing or latent congestive heart failure. Monitoring of cardiovascular status and electrolyte levels is recommended.

Mannitol (Intravenous) can be administered with caution in a hypertensive crisis. However, it is essential to monitor the patient's cardiovascular status and electrolyte levels closely, as mannitol may intensify existing or latent congestive heart failure or obscure and intensify inadequate hydration or hypovolemia. The patient's condition, including their renal function, should be carefully evaluated before administering mannitol 2. Additionally, the dosage and administration of mannitol should be tailored to the individual patient's needs, taking into account their age, weight, and condition 2. It is crucial to be aware of the potential contraindications, such as severe pulmonary congestion or frank pulmonary edema, and to monitor the patient for signs of adverse reactions 2 2.

From the Research

Administration of Mannitol in Hypertensive Crisis

• There is no mention of Mannitol (Intravenous Fertilization) being administered in a hypertensive crisis in the provided studies 3, 4, 5, 6, 7.
• The studies discuss various antihypertensive agents used to treat hypertensive crises, including sodium nitroprusside, labetalol, esmolol, fenoldopam, nicardipine, and clevidipine 3, 4, 5, 6, 7.
• The primary goal of intervention in a hypertensive crisis is to safely reduce blood pressure, and the choice of agent depends on the severity of the crisis and the presence of end-organ damage 3, 4, 5, 6, 7.

Alternative Treatments for Hypertensive Crisis

• Sodium nitroprusside is a commonly used agent for treating hypertensive emergencies, but its use is associated with toxicity and should be avoided if possible 3, 4, 5, 6, 7.
• Other agents, such as labetalol, esmolol, fenoldopam, nicardipine, and clevidipine, are also used to treat hypertensive crises, and their choice depends on the patient's clinical presentation 3, 4, 5, 6.
• Oral antihypertensive agents, such as clonidine and nifedipine, may be used to treat hypertensive urgencies, which are characterized by severe hypertension without acute end-organ damage 4, 6.