Beth Israel Deaconess Medical Center
Transplant Manual
Title: Fulminant Hepatic Failure - Intracranial Pressure Monitoring (ICP)
Purpose: To outline process for clinical management of liver transplant recipients
Policy Statement:
The term fulminant hepatic failure (FHF) is defined as the development of
encephalopathy within 8 weeks of the onset of symptoms in patients who have no
previous history of liver disease. A more recent proposal for the classification of the
condition attempts to achieve a closer alignment between the subcategories of FHF
and the clinical outcome. This uses the core term “acute liver failure” to describe the
onset of encephalopathy within 12 weeks of the onset of jaundice. Hyperacute liver
failure occurs within 7 days, acute liver failure occurs between 8 and 28 days, and
subacute liver failure ranges from 5 to 12 weeks. Patients with hyperacute liver
failure have the highest probability of cerebral edema and prolonged PT, but the best
chance of survival. The incidence of cerebral edema decrease with less acute liver
injury.
Cerebral edema complicates grade 4 encephalopathy and develops in up to 70% of
patients with hyperacute liver failure, 55% of patients with acute liver failure, and
approximately 15% of patients with subacute liver failure. Data in relation to the
impact of increased ICP on the outcome of patients with ALF are scant, but more than
90% mortality is expected in patients with ALF in whom raised ICP cannot be
100
90
Percentage
80
70
60
50
40
30
20
10
0
Survival
Hyperacute liver failure
Cerebral Edema
Acute liver failure
Prothrombin Time
Subacute liver failure
controlled with conventional measures. Thirty-five to 40% of patients die while
awaiting transplant, primarily because of the effects of raised ICP. Liver
transplantation results in survival rates of up to 80% in patients with acute liver failure.
Once a patient progresses to stage III hepatic encephalopathy (HE) (West Haven
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criteria), it is very important to protect the airway, and a formal decision is made to
sedate and mechanically ventilate the patient. In addition, it is important to appreciate
that fever; psychomotor agitation and arterial hypertension are frequently observed
prior to episodes of severe intracranial hypertension.
Which patients should be monitored?
Patients who are candidates for OLT are clearly candidates for ICP monitoring
because of the risk of raised ICP during the hepatic dissection and the anhepatic
phase. Similarly, it is important to identify patients who have prolonged periods of
raised ICP who need to be removed from the liver transplant waiting list. Similarly,
patients with good prognostic features for recovery (i.e. not fulfilling the King’s College
Criteria) but with prolonged hepatic encephalopathy should also be considered
candidates for ICP monitoring.
Risk of ICP monitoring:
Blei et al performed a survey of complications associated with the placement of ICP
monitors in patients with FHF among centers in the US performing liver
transplantation (n=262 patients). Epidural catheters were most commonly used and
associated with the lowest rate of complications (3.8%) compared with subdural
(20%) and parenchymal catheters (22%). Fatal hemorrhage occurred in 1% of
patients with the epidural catheter, 5% with subdural and 4% with parenchymal
catheters. Data from single-center experience show that ICP monitors can be used
safely and can improve management. Ascher et al monitored ICP in 42 OLT
candidates and reported a 92% survival rate. The risks of bleeding can be decreased
by the use of recombinant factor VIIa as demonstrated in a recent study.
Protocol:
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Patient with ALF (the onset of hepatic encephalopathy within 12 weeks of
jaundice).
Grade III-IV hepatic encephalopathy (West Haven criteria) or clinical signs of
raised ICP in a ventilated patient.
Patients are either candidates for OLT or are deemed to have a good
prognosis by conventional criteria (King’s College Hospital Criteria, Hôpital
Paul Brousse criteria).
A head CT will be obtained prior to catheter placement to rule out a possible
intracranial bleed or other pathology contributing to coma.
Prothrombin time and INR will be monitored pre-procedure then every 3 hours
after ICP placement. Platelet count and fibrinogen will be monitored daily,
unless a transfusion is needed to correct them; then a post-transfusion count
should be drawn.
Baseline PT, PTT, INR, platelet count, fibrinogen obtained.
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Pre-procedure
o Platelets corrected to of >100,000/dL.
o Fibrinogen corrected to >150 mg/dL.
o 2 units of FFP, then a dose of rFVIIa (40 mcg/Kg) should be infused.
o STAT PT/INR drawn with a goal of an INR <=1.4.
o If INR >1.4, then a dose of rFVIIa (40 mcg/Kg) should be infused.
o Repeat STAT PT/INR drawn with a goal of an INR <=1.4.
The Neurosurgical team will place the intraparenchymal catheter within 20
minutes of rFVIIa infusion.
Post-procedure
o FFP continuous infusion 100 cc per hour, titrated to INR.
o PT, INR, PTT every 3 hours.
o rFVIIa (20 mcg/Kg) as needed to keep INR <=1.4 for the first 48 hours
then INR <2.0.
o Complete blood count and fibrinogen every 24 hours.
o Platelet count corrected to >75,000/dL. If uremic, hematocrit should be
>=30%, and cryoprecipitate and DDAVP can be administered.
o Fibrinogen corrected to >100 mg/dL.
The ICP will be maintained below 20 mmHg.
The CPP pressure will be maintained above 70 mmHg
Raised ICP will be treated with infusion of 1-2 mg/Kg body weight of mannitol.
This can be repeated as long as serum osmolality <320 mosm/L.
In patients with renal failure, fluid can be removed by ultrafiltration.
Catheter removal
o Either the patient has recovered spontaneously or after OLT, or
prognosis has worsened.
o INR corrected to <=1.4.
o Platelet count corrected to >100000/dL.
o Fibrinogen corrected to >150 mg/dL.
Vice President Sponsor:
Approved by:
x Liver Selection Committee
Requestor Name:
Original Date Approved:
Next Review Date:
Revised:
Dianne Anderson, Sr. VP PCS
Douglas W. Hanto, MD, PhD and Michael Curry, MD
Co-Chairs
Michael Curry, MD
8/05
1/08
12/06
Eliminated:
3