Intracranial pressure monitoring and liver transplantation for fulminant hepatic failure

Abstract

Cerebral edema and intracranial hypertension, commonly present in fulminant hepatic failure, may lead to brainstem herniation and limit the survival of comatose patients awaiting liver transplantation before a donor organ becomes available. Also, they are likely responsible for postoperative neurological morbidity and mortality. Although intracranial pressure monitoring has been proposed to aid clinical decision making in this setting, its use in the prevention of brainstem herniation preoperatively, in the selection of patients for liver transplantation who have the potential for neurological recovery and in the maintenance of cerebral perfusion during liver transplantation has not been examined in detail. To address these issues, we established a protocol for intracranial pressure monitoring in comatose patients with fulminant hepatic failure as part of their preoperative and intraoperative management. Twenty adults and three children underwent intracranial pressure monitoring. Ten patients required preoperative medical therapy with mannitol, barbiturates or both for a rise in intracranial pressure above 25 mm Hg. Four patients had a sustained lowering of intracranial pressure, three of whom survived hospitalization. Six patients had intracranial hypertension refractory to medical management, were removed from a waiting list for a donor organ and died with brainstem herniation. Of the remaining 17 patients, 3 died of other causes while awaiting a donor organ, 2 recovered spontaneously without neurological sequelae and 12 underwent liver transplantation. All but one patient undergoing liver transplantation had transient intraoperative intracranial hypertension develop, requiring medical treatment. The 12 patients who had transplants recovered neurologically and were discharged from the hospital.(ABSTRACT TRUNCATED AT 250 WORDS)

Recombinant activated factor VII for coagulopathy in fulminant hepatic failure compared with conventional therapy

“…Previous studies of ICP monitoring in patients with liver failure suggested that the greatest benefit of these devices occurs intraoperatively, during transplantation, when wide volume swings increase the risk for cerebral edema. 25 This observation, along with the decreased occurrence of anasarca with rFVIIa use, may explain the infrequent need for intervention to treat intracranial hypertension in our patients treated with rFVIIa. Unfortunately, because we were unable to place ICP monitors in most of the control (plasma-treated) patients, we were unable to directly compare the incidence of intracranial hypertension in the two groups.…”

The effect of hypertonic sodium chloride on intracranial pressure in patients with acute liver failure

“…The sample size was based on previously reported data. 9 A difference of 10 mm Hg in mean intracranial pressure (ICP) between groups was anticipated, based on previous anecdotal experience using hypertonic saline to treat patients with ALF. This expectation, together with an ␣ value of 0.05 and a ␤ value of 0.2, yielded a target sample size of 29 patients.…”

Liver transplantation

“…Loss of oculovestibular reflexes and depressed cerebral perfusion pressures that cannot be easily controlled are almost invariably associated with irreversible brain stem damage. 140 Furthermore, patients who require continuous pressor support to maintain an adequate blood pressure cannot tolerate the rigors of major surgery. The APACHE III criteria may be a useful adjunct to clinical judgment in identifying these patients.…”