hypertonic saline + mannitol

Hypertonic saline + mannitol is a combination hyperosmolar therapy used primarily for the management of increased intracranial pressure (ICP) and cerebral edema, particularly in patients with traumatic brain injury (TBI). Both agents work through osmotic mechanisms to reduce brain swelling, though they have distinct mechanisms of action. Mannitol is a sugar alcohol that creates an osmotic gradient across the blood-brain barrier, drawing water from brain tissue into the intravascular space, while also providing rheological effects that reduce blood viscosity. Hypertonic saline works by increasing serum osmolality, creating an osmotic gradient that pulls water from tissues including the brain, and also has beneficial effects on cerebral microcirculation by reducing endothelial cell edema. The combination therapy is sometimes used when either agent alone is insufficient to control intracranial hypertension, though research on the efficacy and safety of the combination compared to monotherapy is still evolving.