Invasive intracranial pressure monitoring is a useful adjunct in the management of severe hepatic encephalopathy associated with pediatric acute liver failure.
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.


METHODS
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.


METHODS
None.


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.
Division of Critical Care, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA. pkee72@hotmail.com
Pradip
P
Kamat
Sachin
S
Kunde
Miriam
M
Vos
Atul
A
Vats
Nitika
N
Gupta
Thomas
T
Heffron
Rene
R
Romero
James D
JD
Fortenberry
D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006501:Hepatic Encephalopathy / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D006801:Humans; D019586:Intracranial Hypertension / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy; D007427:Intracranial Pressure; D017114:Liver Failure, Acute / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D016031:Liver Transplantation / Q000379:methods; D008297:Male; D008991:Monitoring, Physiologic / Q000379:methods*; D011300:Preoperative Care / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D016896:Treatment Outcome; D014850:Waiting Lists
Pediatr Transplant. 2010 Mar;14(2):228-32
19519799
Lancet. 2003 Jul 19;362(9379):192-7
12885479
J Pediatr. 2001 Dec;139(6):871-6
11743517
Hepatology. 2004 Feb;39(2):464-70
14767999
Gastroenterology. 1971 Dec;61(6):877-84
5125688
Neurochem Int. 2005 Jul;47(1-2):71-7
15961187
Pediatr Neurol. 1998 Apr;18(4):299-304
9588523
J Pediatr Gastroenterol Nutr. 1997 Feb;24(2):128-34
9106097
Crit Care Med. 1991 Jun;19(6):758-62
2055051
Curr Opin Organ Transplant. 2010 Jun;15(3):368-73
20489632
Clin Liver Dis. 2006 Feb;10(1):149-68, vii
16376799
Semin Liver Dis. 2008 May;28(2):153-66
18452115
Liver Transpl. 2005 Dec;11(12):1581-9
16315300
Semin Liver Dis. 1996 Nov;16(4):379-88
9027951
J Hepatol. 1993 Jun;18(2):205-9
8409336
N Engl J Med. 2008 May 15;358(20):2127-37
18480205
Semin Liver Dis. 2003 Aug;23(3):251-8
14523678
J Neurosurg. 2007 Apr;106(4):548-56
17432703
Crit Care Med. 2006 Jul;34(7):1981-7
16691131
Transplantation. 1999 Mar 15;67(5):767-70
10096539
Pediatr Emerg Care. 2007 Feb;23(2):129-35
17351416
J Pediatr. 2006 May;148(5):652-658
16737880
J Trauma. 2000 Oct;49(4):654-8; discussion 658-9
11038082
Transplantation. 2003 Jun 27;75(12):2034-9
12829907
Semin Liver Dis. 1996 Nov;16(4):427-33
9027955
Pediatr Crit Care Med. 2003 Apr;4(2):239-42
12749659
Lancet. 1993 Jan 16;341(8838):157-8
8093756
Indian J Gastroenterol. 1998 Apr;17(2):43-5
9563216
Ann Intern Med. 2002 Dec 17;137(12):947-54
12484709
Crit Care Med. 2000 Apr;28(4):1144-51
10809296
Pediatrics. 2009 Mar;123(3):1066-72
19255041
Dev Med Child Neurol. 1999 Apr;41(4):220-5
10355804
J Clin Gastroenterol. 1986 Dec;8(6):664-8
3805667
Gastroenterology. 2003 Sep;125(3):755-64
12949721
Liver Transpl. 2005 Aug;11(8):872-4
16035071
Curr Opin Crit Care. 2004 Apr;10(2):126-31
15075723
Crit Care Med. 2007 Nov;35(11):2498-508
17901832