Luca Roncati, Luca Roncati, M.D.,

Other Contributors:

October 04, 2013

We have read with great interest the article by Rickard et al. [1] concerning with the management of raised intracranial pressure in course of traumatic brain injury. More in detail, the sugar alcohol mannitol, derived from fructose hydrogenation (sorbitol isomer), is a hyperosmolar diuretic agent. Clinically, mannitol can be administered through a central or peripheral venous catheter in the treatment of raised intracranial / intraocular pressure or during surgical and anesthetic procedures [2] at risk for intracranial / intraocular pressure raising. It is well known that high doses of mannitol (more than 200 g/day) can cause acute renal failure and hyperglycemic state, occasionally accompanied by seizures, stupor and coma. The administration of mannitol is therefore to be avoided in uremic and diabetic patients. Recently, our risk management and research group for anaphylaxis has reported the sentinel event of an intraoperative anaphylactic death due to mannitol infusion in an atopic patient with specific IgE against carbohydrate cross-reactive determinants (CCDs) [3]. The administration of mannitol should be avoided in multiallergic patients (e.g. graminaceae, canine grass, peanuts) with specific IgE against CCDs [4-5]. In these patients, especially in life- threatening conditions with the need for intravenous delivery, the administration of hypertonic sodium solution is to be preferred, in order to prevent anaphylactic reactions.


1) Rickard AC, Smith JE, Newell P, Bailey A, Kehoe A, Mann C. Salt or sugar for your injured brain? A meta-analysis of randomised controlled trials of mannitol versus hypertonic sodium solutions to manage raised intracranial pressure in traumatic brain injury. Emerg Med J. Published Online First: 28 June 2013. doi: 10.1136/emermed-2013-202679

2) Schmid P, Wuthrich B. Peranaesthetic anaphylactoid shock due to mannitol. Allergy 1992;47:61-2.

3) Roncati L, Barbolini G, Scacchetti AT, Busani S, Maiorana A. Unexpected death: anaphylactic intraoperative death due to Thymoglobulin carbohydrate excipient. Forensic Sci Int 2013;228:28-32.

4) Hegde VL, Venkatesh YP. Anaphylaxis to excipient mannitol: evidence for an immunoglobulin E-mediated mechanism. Clin Exp Allergy 2004;34:1602-9.

5) Commins SP, Platts-Mills TA. Anaphylaxis syndromes related to a new mammalian cross-reactive carbohydrate determinant. J Allergy Clin Immunol 2009;124:652-7.

Conflict of Interest:

None declared

Conflict of Interest

None declared