甘露醇
甘露醇是一種強效的**滲透性利尿劑**，主要用於急診和重症監護獸醫學。它是一種糖醇，能將水分從細胞內抽吸至細胞外間隙。 **主要適應症：** * 處理**急性少尿性腎衰竭**（促進利尿） * 降低**顱內壓 (ICP)** 和腦水腫（例如創傷性腦損傷） * 降低急性青光眼中的**眼內壓 (IOP)** * 促進特定毒素（如阿斯匹靈、巴比妥類藥物、溴化物、乙二醇）的尿液排泄 > **臨床提示：** 由於甘露醇會引起快速的體液轉移，其療效顯著但需要嚴格監測病患的體液和水合狀態。由於其在室溫下容易結晶，給藥時必須使用輸液過濾器。
作用機制: Mannitol is freely filtered at the glomerulus and poorly reabsorbed in the renal tubules. * **Osmotic Diuresis:** The presence of mannitol in the tubular fluid increases osmotic pressure → prevents water reabsorption → proportionately increases water excretion along with sodium, uric acid, and urea. * **Neuroprotection & ICP Reduction:** Increases intravascular osmolarity → draws water from brain parenchyma across an intact blood-brain barrier (BBB) into the intravascular space → decreases cerebral edema and CSF pressure. * **Renal Protection:** Dilates renal arterioles → decreases vascular resistance and blood viscosity → increases renal blood flow and glomerular filtration rate (GFR). It also minimizes renal tubular swelling and prevents the concentration of nephrotoxins in tubular fluid.
各物種劑量
- Cerebral edema · 1-3 gram/kg IV · IV · Single dose · Usually given with steroids and/or DMSO.
- Oliguric renal failure · 1-2 gram/kg (5-10mL of 20% solution) IV · IV · Single dose · Give after rehydration; monitor urine flow and fluid balance.
- Cerebral edema · 1-3 gram/kg IV · IV · Single dose · Usually given with steroids and/or DMSO.
- Oliguric renal failure · 1-2 gram/kg (5-10mL of 20% solution) IV · IV · Single dose · Give after rehydration; monitor urine flow and fluid balance.
- Oliguric renal failure (not anuric) · 0.25-0.5 gram/kg IV over 5-10 minutes · IV · May repeat q4-6 hours or as CRI for first 12-24 hours · 12-24 hours · After correcting fluid, electrolyte, acid/base balance. CRI dose is 8-10% solution.
- Oliguric renal failure (rehydrated, not fluid overloaded) · 0.25-0.5 gram/kg IV slowly over 5-10 minutes; repeat dose at 30-40 minute intervals up to 1.5 gram/kg total · IV · q30-40min · Up to 1.5 g/kg total
- Oliguric renal failure (fluid replete) · 0.5 gram/kg IV over 20-30 minutes; if significant diuresis is accomplished within 30 minutes, may administer as a CRI of 60-120 mg/kg/hr IV or as intermittent boluses repeated every 4-6 hours · IV · CRI or q4-6h · Contraindicated in patients who are dehydrated, hypervolemic, or anuric.
- Acute glaucoma · 0.5-1 gram/kg IV given over 15-20 minutes · IV · Single dose · Withhold water for 3-4 hours. IOP reduction begins in 20-30 mins.
給藥途徑
禁忌症
- Anuria secondary to renal disease
- Severe dehydration
- Severe pulmonary congestion or pulmonary edema
- Intracranial bleeding (unless during craniotomy - human label)
- Disrupted capillary membrane in the brain (can leak into interstitium and worsen edema)
- Severe pulmonary congestion
- Pulmonary oedema
- Intracranial haemorrhage (relative contraindication; labelled 'use with care' but commonly used in traumatic brain injury)
不良反應
- Fluid and electrolyte imbalances (especially hypernatremia)
- Volume overload (if oliguria persists)
- Nausea and vomiting
- Pulmonary edema
- Congestive heart failure (CHF)
- Tachycardia
- Dizziness and headache (CNS effects)
- Fluid and electrolyte imbalances
- Circulatory overload (at high doses)
- Acidosis (at high doses)
- Thrombophlebitis
- Extravasation injury (oedema and skin necrosis)
- Diarrhoea (if administered orally)
- Acute renal failure (rare)
藥物相互作用
- Lithium · Mannitol can increase the renal elimination of lithium
- Sotalol · Mannitol's effects on potassium and magnesium may increase the risk for QT prolongation
- Potassium-depleting diuretics · May exacerbate diuretic-induced hypokalaemia · moderate
- Beta-blockers · Concurrent use with potassium-depleting diuretics requires caution · moderate
- Ciclosporin · Nephrotoxicity has been described with concurrent use in humans · major
- Whole blood · Mannitol should never be added to whole blood for transfusion or given through the same IV set · major
- KCl or NaCl · Do not add to concentrated mannitol solutions (20% or 25%) as a precipitate may form · major
監測
- Serum electrolytes (especially sodium)
- Serum osmolality
- BUN and serum creatinine
- Urine output
- Central venous pressure (CVP), if possible
- Lung auscultation (to monitor for pulmonary edema)
- Intracranial pressure (ICP) or neurological status
- Intraocular pressure (IOP)
- Hydration status and body weight
- Serum electrolytes (especially potassium and sodium)
- Renal function (BUN, creatinine)
- Acid-base balance
過量
Inadvertent overdosage can cause excessive excretion of sodium, potassium, and chloride. If urine output is inadequate, **water intoxication** or **pulmonary edema** may occur. **Treatment:** * Halt mannitol administration immediately. * Monitor and correct electrolyte and fluid imbalances. * Hemodialysis is effective in clearing mannitol from the bloodstream.
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