Osmotic and osmotic-loop diuresis in brain surgery. Effects on plasma and CSF electrolytes and ion excretion

In 22 patients to be operated on for brain tumors or cerebral aneurysms, the effect of osmotic diuresis was compared with that of osmotic-loop diuresis on plasma and cerebrospinal fluid (CSF) electrolytes, and water and ion excretion. Mannitol or mannitol plus furosemide were used to reduce brain bulk. After treatment with thiopental and hyperventilation, patients received randomly a rapid infusion of mannitol (1.4 gm/kg), or mannitol (1.4 gm/kg) plus furosemide (0.3 mg/kg). Brain shrinkage was considerably greater and more consistent with mannitol plus furosemide than with mannitol alone. However, hyponatremia, hypokalemia, hypochloremia, and hyperosmolality were also more marked (p less than 0.05) with mannitol plus furosemide than with mannitol. The rate of water and ion excretion was even more striking. At 30 minutes after absorption of mannitol alone, water excretion peaked at 17 ml/min, and gradually decreased to 3.8 ml/min 70 minutes later. With mannitol plus furosemide, during an identical time course, initial water excretion was 30 ml/min, followed by a further rise to 42 ml/min and then a decline to 17 ml/min. At peak diuresis after mannitol, Na+ and Cl- excretion average 0.57 and 0.62 mEq/min, respectively. This compares with mean values of 3.7 and 4.12 mEq/min for Na+ and Cl-, respectively, after mannitol plus furosemide. Although optimum brain shrinkage is achieved with osmotic-loop diuresis, the rapid electrolyte depletion (Na+ and Cl-) must be corrected to avoid altered sensorium during the patients' postoperative course.