Departments of Neurosurgery and Neurology, University of Michigan, 3552 Taubman Health Care Center, 1500 East Medical Center Drive, SPC 5338, Ann Arbor, MI, 48109-5338, USA.
Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
Crit Care. 2017 Jul 11;21(1):178. doi: 10.1186/s13054-017-1762-6.
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). 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.
Adult 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/mm 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.
A 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).
Protocol-directed use of IICPM in ALF is feasible, associated with a low incidence of serious complications and has a significant impact on clinical management.
急性肝衰竭（ALF）可能导致颅内压升高（ICP）。虽然有创 ICP 监测（IICPM）可能在 ALF 管理中发挥作用，但这些患者通常存在凝血功能障碍，并有颅内出血（ICH）的风险。当代 ICP 监测技术和凝血功能障碍逆转策略可能与出血风险降低相关。我们的目的是评估在 ALF 中，根据协议指导使用 IICPM 的安全性、可行性、对临床管理的影响和结果。
2011 年 6 月至 2016 年 10 月期间，符合以下条件的成年 ALF 患者（伴 4 级肝性脑病，且存活可能性较大）被纳入研究：可行 IICPM；接受重组 VII 因子（rFVIIa）和去氨加压素治疗，目标血小板计数＞50,000/mm³，纤维蛋白原＞100mg/dL。rFVIIa 剂量后 1 小时内进行监测器插入。仅使用脑内监测器。在放置监测器之前和之后 24 小时内进行脑部计算机断层扫描。感兴趣的结果包括 ICH、持续颅内高压、ICP 管理的治疗强度水平（TIL）、死亡率和出院时及 6 个月时格拉斯哥结局量表（GOS）的功能结局。
共有 24/37 例（65%）ALF 患者接受了 IICPM。最常见的排除原因是脑病分级＜4 级。4 例患者接受了肝移植。1 例患者在 IICPM 后出现无症状性 ICH，但结局良好。24 例监测患者中有 13 例（54%）发生持续颅内高压，5 例（21%）需要（TIL-4）极端 ICP 控制措施，4 例患者成功：24 例患者中有 12 例（50%）死亡，但只有 4 例（17%）死亡归因于颅内高压。8 例存活患者中有 6 例（75%）在 6 个月随访时有良好的功能结局（GOS＞3）。
在 ALF 中，根据协议指导使用 IICPM 是可行的，其严重并发症发生率较低，并对临床管理产生重大影响。
