Protocol based invasive intracranial pressure monitoring in acute liver failure: feasibility, safety and impact on management

Venkatakrishna Rajajee,Parag G. Patil,Robert J. Fontana,Anthony J. Courey

doi:10.1186/s13054-017-1762-6

Venkatakrishna Rajajee, Parag G. Patil + Show 2 more

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https://doi.org/10.1186/s13054-017-1762-6

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Journal: Critical Care	Publication Date: Jul 11, 2017
Citations: 31	License type: open-access

Affiliation: University of Michigan–Ann Arbor

Abstract

BackgroundAcute liver failure (ALF) may result in elevated intracranial pressure (ICP). While invasive ICP monitoring (IICPM) may have a role in ALF management, these patients are typically coagulopathic and at risk for intracranial hemorrhage (ICH). Contemporary ICP monitoring techniques and coagulopathy reversal strategies may be associated with a lower risk of hemorrhage. Our objective was to evaluate the safety, feasibility, impact on clinical management and outcomes associated with protocol-directed use of IICPM in ALF.MethodsAdult patients admitted between June 2011 and October 2016, with ALF and grade-4 encephalopathy with a reasonable likelihood of survival, were eligible for IICPM. The coagulopathy reversal protocol included administration of recombinant Factor VIIa (rFVIIa) and desmopressin, a goal platelet count >50,000/mm3 and fibrinogen >100 mg/dL. Monitor insertion was performed within an hour of the rFVIIa dose. Only intraparenchymal monitors were used. Computed tomography of the brain was performed prior to and within 24 hours of monitor placement. Outcomes of interest included ICH, sustained intracranial hypertension, therapeutic intensity level (TIL) for ICP management, mortality and functional outcome on the Glasgow Outcome Scale (GOS) at discharge and 6 months.ResultsA total of 24/37 patients (65%) with ALF underwent IICPM. The most common reason for exclusion was encephalopathy grade <4. Four patients underwent liver transplantation. There was one asymptomatic ICH following IICPM, in a patient who had an excellent outcome. Sustained intracranial hypertension occurred in 13/24 monitored patients (54%), 5/24 (21%) required extreme measures (TIL-4) for ICP control, which were successful in 4 patients: 12/24 patients (50%) died but only 4 deaths (17%) were attributed to intracranial hypertension. Six of the 8 survivors with 6-month follow up had good functional outcome (GOS >3).ConclusionsProtocol-directed use of IICPM in ALF is feasible, associated with a low incidence of serious complications and has a significant impact on clinical management.

Highlights

Acute liver failure (ALF) may result in elevated intracranial pressure (ICP)
In view of the potential risk associated with the intervention, we created a database to prospectively track complications associated with invasive ICP monitoring (IICPM) use, the frequency with which intracranial hypertension was detected, changes in management following detection of intracranial hypertension and clinical outcomes
Additional outcomes studied were the incidence of sustained intracranial hypertension defined as ICP >20 mmHg for >10 mins in a 1-hour period with the patient at rest, therapeutic intensity directed at management of ICP as documented by a therapeutic intensity level (TIL) basic score [33], incidence of all arterial and venous thromboembolic events, incidence of any other complications attributable to IICPM including infection, mortality, functional status at discharge and functional status at 6 months

Summary

Introduction

Acute liver failure (ALF) may result in elevated intracranial pressure (ICP). While invasive ICP monitoring (IICPM) may have a role in ALF management, these patients are typically coagulopathic and at risk for intracranial hemorrhage (ICH). ALF patients, by definition are coagulopathic, and at risk for life-threatening intracranial hemorrhage following monitor insertion [1, 24, 25]. Epidural/ subdural bolts are rarely used today because of concerns about technical accuracy and overestimation of ICP [29, 30] In these earlier studies, recombinant Factor VIIa (rFVIIa), which is more effective than fresh frozen plasma (FFP) as a reversal agent [1, 14, 31, 32], was not consistently utilized prior to insertion. Some centers have described a relatively low risk of complications with the consistent use of intraparenchymal monitors following administration of rFVIIa [10, 14, 23]

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