Manitol may be used if the patient does not respond to volume. Start by giving manitol at 12.5 to 25 gramsgrams and may repeat the same dose inone hour if no result. When giving multiple doses of multiple doses of manitol remember that we have to periodically check the serum osmolality to assure that it is less than 310. If the measured serum osmolality is greater than 310, do not give any further manitol. From an academic standpoint, manitol works well in these patients because it is a volume expander, osmotic diuretic, and oxygen free radical scavenger.
Several textbooks write about the use of sodium bicarbonate to alkalize the urine.
The pH of the urine has to be increased above 4.5. This is VERY difficult to do an requires larger amounts of sodium bicarbonate. My personal observation and bias is that administration of bicarbonate improves UO prior to alkalization of the urine because of the large sodium load. Remember that pushing an amp of sodium bicarbonate is similar to giving a small hyertonic saline bolus. Adults do not routinely receive dextrose containing fluids in the first twenty-four hours.