Raschke Robert A, Curry Steven C, Rempe Silke, Gerkin Richard, Little Ester, Manch Richard, Wong Mark, Ramos Alberto, Leibowitz Alan I
Banner Good Samaritan Medical Center, Phoenix, AZ, USA.
Crit Care Med. 2008 Aug;36(8):2244-8. doi: 10.1097/CCM.0b013e31818029a3.
To assess the safety and efficacy of a protocol to support management of intracerebral pressure in patients with fulminant liver failure (FLF).
A prospective series was conducted between May 2004 and September 2006 at Banner Good Samaritan Medical Center, a 650-bed teaching hospital in Phoenix, Arizona.
We recruited consecutive patients with FLF and stage 3 or 4 encephalopathy.
We placed an intracranial pressure monitor in each patient and employed a protocol to support decisions regarding hemostatic management and prevention and treatment of intracranial hypertension (IHTN). Treatment modalities included hypothermia, hypocarbia, intravenous pentobarbital, intravenous mannitol and vasopressor titration for maintenance of cerebral perfusion pressure. The main outcome measure was survival in transplant candidates.
Twenty-two patients entered the study and 21 (95%) had at least one episode of IHTN. Eighty-two discrete episodes of IHTN occurred, and 78 of these (95%) resolved with treatment. Overall survival was 55%. Eleven of 18 (61%) of transplant candidates survived with good neurologic outcome. No patient died from isolated cerebral edema. Three patients had intracranial hemorrhages related to the intracranial pressure monitor.
Protocol-driven management of intracranial pressure in FLF can result in good clinical outcomes in most transplant candidates, even if IHTN occurs.
评估一项支持暴发性肝衰竭（FLF）患者颅内压管理方案的安全性和有效性。
2004年5月至2006年9月在亚利桑那州凤凰城一家拥有650张床位的教学医院班纳善玛利亚医疗中心进行了一项前瞻性系列研究。
我们招募了连续的FLF且伴有3或4期肝性脑病的患者。
我们为每位患者放置了颅内压监测器，并采用一项方案来支持有关止血管理以及颅内高压（IHTN）预防和治疗的决策。治疗方式包括低温、低碳酸血症、静脉注射戊巴比妥、静脉注射甘露醇以及血管升压药滴定以维持脑灌注压。主要结局指标是移植候选者的生存率。
22名患者进入研究，21名（95%）至少有一次IHTN发作。发生了82次离散的IHTN发作，其中78次（95%）经治疗后缓解。总体生存率为55%。18名移植候选者中有11名（61%）存活且神经功能结局良好。没有患者死于单纯性脑水肿。3名患者发生了与颅内压监测器相关的颅内出血。
即使发生IHTN，FLF患者颅内压的方案驱动管理在大多数移植候选者中也可带来良好的临床结局。
