Patients with fulminant hepatic failure progressing to grade 4 encephalopathy are at high risk of development of intracranial hypertension. Intracranial pressure monitoring in this patient population has been shown to increase the duration of survival from the onset of grade 4 encephalopathy and results in altered treatment compared with patients who are not monitored (Keaysefa/ 1993). Additionally, intracranial pressure monitoring provides important prognostic information in this group. Patients with prolonged uncontrollable elevations in intracranial pressure and reduced cerebral perfusion pressure have an increased chance of permanent neurological deficit and may not be appropriate candidates for transplantation. Special consideration should be given to the profound coagulopathy that is present in all patients with fulminant hepatic failure. Epidural devices are recommended in these cases because of the high rate of hemorrhagic complications associated with the use of intraventricular, intraparenchymal, and subdural monitors.
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