Announcements: Neuromuscular section updated with more questions.

For a patient with ICP monitoring:  Mannitol 1 g/kg q6hr PRN ICP ≥ X, Hold for Osm Gap > 10 or Na > 160 or Serum Osm > 320

For a patient without ICP monitoring: Mannitol 1 g/kg q6hr, Hold for Osm Gap > 10 or Na > 160 or Serum Osm > 320

Check Na, BUN, Cr, Gluc, Osm q6hr, one hour before mannitol dosing

Is Osm Gap >10 or Na > 160 or Serum Osm > 320?
    ↓                                                                    ↓
      Yes                                                              No
                                     Hold Mannitol                 Administer next dose if indicated by ICP


Osm Gap = measured Osm – calculated Osm

Calculated Osm = 2(Na) + BUN/2.8 + Glu/18 + 10

Osm gap < 0 may be due to miscalculation or minor variation in lab values; mannitol may be given if calculation correct

May order hypertonic saline in the presence of a gap

Unexpected gaps may be caused by alcohol or propylene glycol carrier (lorazepam, diazepam, midazolam, pentobarb and phenobarb)

Adapted from


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