title: Emergent, controlled lumbar drainage for intracranial pressure monitoring during orthotopic liver transplantation.
abstract: BACKGROUND
  Measurement of intracranial pressure (ICP) is recommended in comatose acute liver failure (ALF) patients due to risk of rapid global cerebral edema. External ventricular drains (EVD) can be placed to drain cerebrospinal fluid and monitor ICP simultaneously although this remains controversial in the neurosurgical community given the risk of hemorrhagic complications. We describe a patient with ALF and global cerebral edema whose EVD failed immediately before orthotopic liver transplantation (OLT) in which a lumbar drain (LD) was used temporarily to monitor ICP.
  
  
  METHODS
  We describe a 36 year old patient with ALF and brain edema from acetaminophen overdose who had an EVD placed for ICP monitoring and management. The EVD failed repeatedly (i.e., lost CSF drainage and ICP waveform) despite several saline irrigations and three doses intraventricular tissue plasminogen activator (1 mg) in the hours that immediately preceded her planned emergency OLT. An LD was placed emergently and controlled cerebrospinal fluid (CSF) drainage and ICP measurement was performed by setting the LD at 20 mmHg and leveling at the ear level (foramen of Monro). The LD was removed once the EVD flow was re-established post-OLT.
  
  
  RESULTS
  The EVD and LD ICP measurements were reported to be the same just prior to removing the LD.
  
  
  CONCLUSIONS
  Controlled CSF drainage using a lumbar drain can be used to monitor ICP when leveled at the foramen of Monro if EVD failure occurs perioperatively. The LD can temporarily guide ICP management until the EVD flow can be re-established after OLT.
authors.affiliation: Department of Anesthesia, Mayo Clinic, Jacksonville, FL, USA.
authors.forename: C Joseph
authors.initials: CJ
authors.lastname: Bacani
authors.forename: W D
authors.initials: WD
authors.lastname: Freeman
authors.forename: Rachel A
authors.initials: RA
authors.lastname: Di Trapani
authors.forename: Juan C
authors.initials: JC
authors.lastname: Canabal
authors.forename: Lisa
authors.initials: L
authors.lastname: Arasi
authors.forename: Timothy
authors.initials: T
authors.lastname: Shine
authors.forename: Darrin L
authors.initials: DL
authors.lastname: Willingham
mesh_terms: D000082:Acetaminophen / Q000633:toxicity; D000328:Adult; D018712:Analgesics, Non-Narcotic / Q000633:toxicity; D001929:Brain Edema / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D004322:Drainage / Q000295:instrumentation*; D062787:Drug Overdose / Q000150:complications; D005260:Female; D005500:Follow-Up Studies; D006501:Hepatic Encephalopathy / Q000139:chemically induced / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D007427:Intracranial Pressure / Q000502:physiology*; D007431:Intraoperative Complications / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy; D016031:Liver Transplantation; D016343:Monitoring, Intraoperative / Q000295:instrumentation*; D009460:Neurologic Examination; D013129:Spinal Puncture / Q000295:instrumentation*; D014057:Tomography, X-Ray Computed
chemical_list: D018712:Analgesics, Non-Narcotic; D000082:Acetaminophen