Document Detail

Invasive intracranial pressure monitoring is a useful adjunct in the management of severe hepatic encephalopathy associated with pediatric acute liver failure.
MedLine Citation:
PMID:  21263362     Owner:  NLM     Status:  MEDLINE    
OBJECTIVE: Pediatric acute liver failure is often accompanied by hepatic encephalopathy, cerebral edema, and raised intracranial pressure. Elevated intracranial pressure can be managed more effectively with intracranial monitoring, but acute-liver-failure-associated coagulopathy is often considered a contraindication for invasive monitoring due to risk for intracranial bleeding. We reviewed our experience with use of early intracranial pressure monitoring in acute liver failure in children listed for liver transplantation.
DESIGN AND PATIENTS: Retrospective review of all intubated pediatric acute liver failure patients with grade III and grade IV encephalopathy requiring intracranial pressure monitoring and evaluated for potential liver transplant who were identified from an institutional liver transplant patient database from 1999 to 2009.
MEASUREMENTS AND MAIN RESULTS: A total of 14 patients were identified who met the inclusion criteria. Their ages ranged from 7 months to 20 yrs. Diagnoses of acute liver failure were infectious (three), drug-induced (seven), autoimmune hepatitis (two), and indeterminate (two). Grade III and IV encephalopathy was seen in ten (71%) and four (29%) patients, respectively. Computed tomography scans before intracranial pressure monitor placement showed cerebral edema in five (35.7%) patients. Before intracranial pressure monitor placement, fresh frozen plasma, vitamin K, and activated recombinant factor VIIa were given to all 14 patients, with significant improvement in coagulopathy (p < .04). The initial intracranial pressure ranged from 5 to 50 cm H2O; the intracranial pressure was significantly higher in patients with cerebral edema by computed tomography (p < .05). Eleven of 14 (78%) patients received hypertonic saline, and three (22%) received mannitol for elevated intracranial pressure. Eight of 14 (56%) monitored patients were managed to liver transplant, with 100% surviving neurologically intact. Four of 14 (28%) patients had spontaneous recovery without liver transplant. Two of 14 (14%) patients died due to multiple organ failure before transplant. One patient had a small 9-mm intracranial hemorrhage but survived after receiving a liver transplant. No patient developed intracranial infection.
CONCLUSIONS: In our series of patients, intracranial pressure monitoring had a low complication rate and was associated with a high survival rate despite severe hepatic encephalopathy and cerebral edema in the setting of pediatric acute liver failure. In our experience, monitoring of intracranial pressure allowed interventions to treat increased intracranial pressure and provided additional information regarding central nervous system injury before liver transplant. Further study is warranted to confirm if monitoring allows more directed intracranial pressure therapy and improves survival in pediatric acute liver failure.
Pradip Kamat; Sachin Kunde; Miriam Vos; Atul Vats; Nitika Gupta; Thomas Heffron; Rene Romero; James D Fortenberry
Publication Detail:
Type:  Journal Article; Research Support, N.I.H., Extramural    
Journal Detail:
Title:  Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies     Volume:  13     ISSN:  1529-7535     ISO Abbreviation:  Pediatr Crit Care Med     Publication Date:  2012 Jan 
Date Detail:
Created Date:  2012-01-06     Completed Date:  2012-05-09     Revised Date:  2014-09-08    
Medline Journal Info:
Nlm Unique ID:  100954653     Medline TA:  Pediatr Crit Care Med     Country:  United States    
Other Details:
Languages:  eng     Pagination:  e33-8     Citation Subset:  IM    
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MeSH Terms
Child, Preschool
Cohort Studies
Follow-Up Studies
Hepatic Encephalopathy / complications,  diagnosis,  therapy*
Intracranial Hypertension / etiology*,  physiopathology,  therapy
Intracranial Pressure
Liver Failure, Acute / complications,  diagnosis,  surgery*
Liver Transplantation / methods
Monitoring, Physiologic / methods*
Preoperative Care / methods
Retrospective Studies
Risk Assessment
Survival Analysis
Treatment Outcome
Waiting Lists*
Grant Support
5 U01 DK084585-02/DK/NIDDK NIH HHS; K23 DK080953/DK/NIDDK NIH HHS; K23 DK080953-01A1/DK/NIDDK NIH HHS; K23DK080953/DK/NIDDK NIH HHS; U01 DK084585-01/DK/NIDDK NIH HHS; U01 DK084585-02/DK/NIDDK NIH HHS
Comment In:
Pediatr Crit Care Med. 2011 Nov;12(6):694-5; author reply 695-6   [PMID:  22067827 ]
Pediatr Crit Care Med. 2012 Jan;13(1):114-5   [PMID:  22222656 ]

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