What are the side effects of intravenous (IV) mannitol?

Side Effects of Intravenous Mannitol

Intravenous mannitol can cause serious adverse effects including fluid and electrolyte imbalances, renal failure, pulmonary edema, and central nervous system toxicity, requiring careful monitoring during administration. 1

Common Side Effects

• Fluid and Electrolyte Disturbances:

  • Hypernatremia or hyponatremia
  • Electrolyte loss
  • Dehydration
  • Acidosis 1

• Cardiovascular Effects:

  • Hypotension
  • Tachycardia
  • Congestive heart failure
  • Pulmonary edema (especially with rapid infusion)
  • Angina-like chest pains 1

• Neurological Effects:

  • Headache
  • Dizziness
  • Blurred vision
  • Convulsions
  • Potential worsening of intracranial hypertension in children within 24-48 hours post-injury 1, 2

• Gastrointestinal Effects:

  • Nausea
  • Vomiting
  • Dryness of mouth
  • Thirst 1

• Local Reactions:

  • Thrombophlebitis
  • Skin necrosis
  • Arm pain at infusion site 1

• Other:

  • Urinary retention
  • Marked diuresis
  • Rhinitis
  • Chills
  • Fever
  • Urticaria 1

Serious Adverse Effects

Renal Complications

Mannitol can cause acute renal failure, particularly:

• When administered in high doses (>200 g/day or >400 g cumulative in 48 hours) 3
• In patients with pre-existing renal disease
• When used with other nephrotoxic drugs or diuretics 1
• Even in patients with previously normal renal function 4

The mechanism may involve:

• Intense tubuloglomerular feedback response
• Tubular cell swelling with luminal obstruction 4
• Renal vasoconstriction at high doses 3

Fluid Overload and Pulmonary Complications

• Too rapid infusion can cause intracellular water to shift into extracellular compartment
• Overexpansion of intravascular space
• Pulmonary congestion and edema 1
• Particularly dangerous in patients with cardiac issues

Central Nervous System Toxicity

• May increase cerebral blood flow
• Risk of postoperative bleeding in neurosurgical patients
• Can worsen intracranial hypertension in certain cases 1, 2

Risk Factors for Adverse Effects

• Pre-existing renal disease
• Conditions predisposing to renal failure
• Concomitant use of nephrotoxic drugs
• Severe dehydration
• Heart failure
• Advanced age
• Altered body water content relative to body weight 1, 5

Monitoring Recommendations

• Regular assessment of renal function
• Monitoring of cardiovascular status
• Frequent electrolyte measurements
• Discontinue mannitol if:
  • Renal function worsens
  • Cardiac status deteriorates
  • Pulmonary status declines
  • CNS toxicity develops 1

Management of Mannitol Toxicity

• Discontinuation of mannitol
• For mannitol-induced acute renal failure, hemodialysis is effective:
  • Rapidly removes mannitol
  • Resolves anuria
  • Accelerates recovery of renal function 3
• Extracorporeal ultrafiltration may also be beneficial 6

Precautions

• Avoid repeated doses in patients with persistent oliguria
• Carefully adjust dosage based on clinical response
• Avoid concomitant administration of nephrotoxic drugs
• Use with caution in patients with heart failure 1

Mannitol is contraindicated in patients with:

• Well-established anuria due to severe renal disease
• Severe pulmonary congestion or frank pulmonary edema
• Active intracranial bleeding (except during craniotomy)
• Severe dehydration
• Progressive heart failure after starting mannitol therapy
• Known hypersensitivity to mannitol 1