Intracranial pressure monitoring in acute liver failure: a review of 10 years experience

Peck, Marcus; Wendon, J.; Sizer, Elizabeth; Auzinger, G.; Bernal, William

doi:10.1186/cc8774

Cited by 10 publications

(8 citation statements)

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“…A number of pro-coagulant pathways are activated that result in an increase in clot strength with increasing severity of liver injury (21). Our bleeding rate of 5–7% is similar to previous studies (9, 12) and lower than the reports from the 1990s (11). Similar rates have been reported by Kamat and colleagues recently (2012) in the pediatric literature as well (24).…”

Section: Discussionsupporting

confidence: 90%

“…In our earlier study, the overall rate of hemorrhage was similar (10.3% experienced bleeding complications), half of these were incidental radiographic findings and not clinically significant (9). In a more recent study of 117 ALF patients from King’s College Hospital, 3 patients (2.5%) developed intracranial hemorrhage after ICPM placement (12). Current conventional parameters (INR, prothrombin time, fibrinogen) do not reliably estimate hemostatic potential and bleeding risk in ALF (20, 21).…”

Section: Discussionmentioning

confidence: 99%

“…An initial survey across medical centers in the United States described a complication rate of roughly 10% (27/263) with significantly higher rates in subdural or parenchymal compared with epidural transducers (11). More recent studies from the US (2005) and the United Kingdom (2010) have published rates of intracranial hemorrhage between 2.5 and 10% (9, 12). …”

Section: Introductionmentioning

confidence: 99%

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Outcomes and Complications of Intracranial Pressure Monitoring in Acute Liver Failure

Karvellas

Fix

Battenhouse

et al. 2014

Critical Care Medicine

120

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Objective To determine if intracranial pressure (ICP) monitor placement in acute liver failure (ALF) patients is associated with significant clinical outcomes. Design Retrospective multicenter cohort study. Setting Academic liver transplant centers comprising the US ALF Study Group. Patients and participants Adult critically ill ALF patients presenting with Grade III/IV hepatic encephalopathy (n=629) prospectively enrolled between 3/2004 to 8/2011. Intervention ICP monitored (ICPM; n=140) vs. non-monitored controls (n=489). Measurements and Results ICPM patients were younger than controls (35 vs. 43 years, p<0.001) and more likely to be on renal replacement therapy (52% vs. 38%, p=0.003). Of 87 ICPM patients with detailed information, 44 (51%) had evidence of intracranial hypertension (ICH ~ ICP >25 mmHg) and overall 21-day mortality was higher in patients with ICH (43% vs. 23%, p=0.05). During the first 7 days, ICPM patients received more ICH-directed therapies (mannitol: 56% vs. 21%; hypertonic saline: 14% VS. 7%; hypothermia: 24% vs. 10%; p< 0.03 for each). 41% of ICPM patients received LT (vs. 18% controls; p<0.001). Overall 21-day mortality was similar (ICPM 33% vs. controls 38%, p=0.24). Where data were available, hemorrhagic complications in ICPM patients were rare (4/56 (7%); 3 died). When stratifying by acetaminophen (APAP) status and adjusting for confounders, ICPM placement did not impact 21-day mortality in APAP patients (p=0.89). However, ICPM was associated with increased 21-day mortality in non-APAP patients (OR ~ 3.04, p=0.014). Conclusions In ICP monitored ALF patients, ICH is commonly observed. The use of ICPM in APAP ALF did not confer a significant 21-day mortality benefit while in non-APAP ALF it may be associated with worse outcomes. Hemorrhagic complications from ICPM placement were uncommon and cannot account for mortality trends. While our results cannot conclusively confirm or refute the utility of ICP monitoring in ALF patients, patient selection and ancillary assessments of cerebral blood flow likely have a significant role. Prospective studies would be required to conclusively account for confounding by illness severity and transplant.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Outcomes and Complications of Intracranial Pressure Monitoring in Acute Liver Failure

Karvellas

Fix

Battenhouse

et al. 2014

Critical Care Medicine

120

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“…27 Yet, the use of subdural and subarachnoid catheters has not been associated with better outcomes in patients with acute liver failure. [28][29][30][31][32] Patients with findings suggestive of cerebral edema are managed similar to those with traumatic brain injury, using bolus therapy of mannitol or hypertonic saline. Treatment aims to maintain a serum sodium of 145 to 155 mmol/L and use of hypertonic saline when indicated has shown to improve outcome in ALF.…”

Section: Neurological Supportmentioning

confidence: 99%

Small-for-Size Syndrome: Bridging the Gap Between Liver Transplantation and Graft Recovery

Rajakumar¹,

Kaliamoorthy²,

Rela³

et al. 2017

Semin Cardiothorac Vasc Anesth

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In living donor liver transplantation, optimal graft size is estimated from values like graft volume/standard liver volume and graft/recipient body weight ratio but the final functional hepatic mass is influenced by other donor and recipient factors. Grafts with insufficient functional hepatic mass can produce a life-threatening condition with rapidly progressive liver failure called small-for-size syndrome (SFSS). Diagnosis of SFSS requires careful surveillance for signs of inadequate hepatocellular function, residual portal hypertension, and systemic inflammation that suggest rapidly progressive liver failure. Early diagnosis, symptom control, and addressing the cause of SFSS may prevent the need for retransplantation. With increased attention to avoiding donor risk, intensivists will be confronted with more SFSS recipients. In this review, we aim to outline a systematic approach to the medical management of patients with SFSS by providing a concise synopsis of general supportive care-neurological, cardiovascular, and renal support, mechanical ventilation, nutritional support, infection control, and tailored immunosuppression-with an aim to avoid end-organ damage or death and a review of current interventions including liver support devices, portal flow modulating drugs, and other experimental interventions that aim to preserve existing hepatic mass and improve conditions for hepatic regeneration. We examine evidence for SFSS interventions to provide the reader with information that may assist in clinical decision making. Points of controversy in care are purposefully highlighted to identify areas where additional experimental work is still needed. A full understanding of the pathophysiology of SFSS and measures to support liver regeneration will guide effective management.

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“…The HE in ALF is multifactorial and can rapidly progress to cerebral oedema and raised intracranial pressure (ICP), with intracranial hypertension (ICH) (ICP>25 mmHg) predisposing to cerebral herniation and death. Currently available tools to monitor HE in ALF include invasive intracranial pressure monitoring, 12 jugular venous oxygen saturation, 13,14 transcranial Doppler 15 and optic nerve sheath diameter assessment (ONSD). 16 Near-infrared spectrophotometry, optic nerve ultrasound and serum biomarkers of brain injury are of future interest.…”

mentioning

confidence: 99%

Update in Hepatic Encephalopathy - Part Ii

Premkumar

Dhiman

2018

Journal of Clinical and Experimental Hepatology

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Intracranial pressure monitoring in acute liver failure: a review of 10 years experience

Cited by 10 publications

References 0 publications

Outcomes and Complications of Intracranial Pressure Monitoring in Acute Liver Failure

Outcomes and Complications of Intracranial Pressure Monitoring in Acute Liver Failure

Small-for-Size Syndrome: Bridging the Gap Between Liver Transplantation and Graft Recovery

Update in Hepatic Encephalopathy - Part Ii

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