The role of Intracranial pressure monitoring

Despite the well-described clinical signs in patients with ALF and cerebral edema, the correlation between the intracranial pressure level and specific clinical signs is poor. Consequently, intracranial pressure monitoring has become increasingly used in ALF to guide therapy of cerebral edema, to identify circumstances that increase intracranial pressure (e.g. endotracheal suction), to select patients for transplantation, and to assist in intraoperative management. Several uncontrolled studies suggest that intracranial pressure monitoring is of benefit, and slightly more than half of liver transplantation programs in the United States regularly use intracranial pressure monitoring for patients with ALF (Hoofnagie... .et..al 1995). Monitors in the extradural space are preferred since the complication rate (4 per cent) is lower than that associated with subdural (20 per cent) or parenchymal (22 per cent) monitors. Deaths caused directly by the monitor are due to intracranial bleeding or, more rarely, infection. The incidence is below 1 per cent for extradural monitors, but 4 to 5 per cent for other types. Most units using intracranial pressure monitoring place the monitors when grade IV encephalopathy develops. A cerebral CT scan is first obtained and the coagulopathy is reversed with infusions of fresh frozen plasma. In general, the goals of therapy are to maintain intracranial pressure below 20 mmHg and cerebral perfusion pressure above 50 mmHg. Recovery is unlikely when intracranial pressure is sustained above 40 mmHg, and a cerebral perfusion pressure below 40 mmHg for more than 2 h is considered to be a contraindication to proceeding with urgent liver transplantation. Although intracranial pressure monitors have been widely used for patients with ALF, the hazards must be considered. A death from intracranial hemorrhage in a patient who might otherwise have survived is a catastrophic event. The indications should be considered individually in each patient. Excellent results have been obtained without their use.

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