Outcomes and complications of intracranial pressure monitoring in acute liver failure

A retrospective cohort study

Constantine J. Karvellas, Oren K. Fix, Holly Battenhouse, Valerie Durkalski, Corron Sanders, William M. Lee

Research output: Contribution to journalArticle

62 Citations (Scopus)

Abstract

Objective: To determine if intracranial pressure monitor placement in patients with acute liver failure is associated with significant clinical outcomes. Design: Retrospective multicenter cohort study. Setting: Academic liver transplant centers comprising the U.S. Acute Liver Failure Study Group. Patients: Adult critically ill patients with acute liver failure presenting with grade III/IV hepatic encephalopathy (n = 629) prospectively enrolled between March 2004 and August 2011. Intervention: Intracranial pressure monitored (n = 140) versus nonmonitored controls (n = 489). Measurements and Main Results: Intracranial pressure monitored patients were younger than controls (35 vs 43 yr, p < 0.001) and more likely to be on renal replacement therapy (52% vs 38%, p = 0.003). Of 87 intracranial pressure monitored patients with detailed information, 44 (51%) had evidence of intracranial hypertension (intracranial pressure > 25 mm Hg) and overall 21-day mortality was higher in patients with intracranial hypertension (43% vs 23%, p = 0.05). During the first 7 days, intracranial pressure monitored patients received more intracranial hypertension-directed therapies (mannitol, 56% vs 21%; hypertonic saline, 14% vs 7%; hypothermia, 24% vs 10%; p < 0.03 for each). Forty-one percent of intracranial pressure monitored patients received liver transplant (vs 18% controls; p < 0.001). Overall 21-day mortality was similar (intracranial pressure monitored 33% vs controls 38%, p = 0.24). Where data were available, hemorrhagic complications were rare in intracranial pressure monitored patients (4 of 56 [7%]; three died). When stratifying by acetaminophen status and adjusting for confounders, intracranial pressure monitor placement did not impact 21-day mortality in acetaminophen patients (p = 0.89). However, intracranial pressure monitor was associated with increased 21-day mortality in nonacetaminophen patients (odds ratio, ~ 3.04; p = 0.014). Conclusions: In intracranial pressure monitored patients with acute liver failure, intracranial hypertension is commonly observed. The use of intracranial pressure monitor in acetaminophen acute liver failure did not confer a significant 21-day mortality benefit, whereas in nonacetaminophen acute liver failure, it may be associated with worse outcomes. Hemorrhagic complications from intracranial pressure monitor placement were uncommon and cannot account for mortality trends. Although our results cannot conclusively confirm or refute the utility of intracranial pressure monitoring in patients with acute liver failure, patient selection and ancillary assessments of cerebral blood flow likely have a significant role. Prospective studies would be required to conclusively account for confounding by illness severity and transplant.

Original languageEnglish (US)
Pages (from-to)1157-1167
Number of pages11
JournalCritical Care Medicine
Volume42
Issue number5
DOIs
StatePublished - 2014

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Acute Liver Failure
Intracranial Pressure
Cohort Studies
Retrospective Studies
Intracranial Hypertension
Mortality
Acetaminophen
Transplants
Cerebrovascular Circulation
Hepatic Encephalopathy
Liver
Physiologic Monitoring
Mannitol
Hypothermia
Critical Illness
Patient Selection
Multicenter Studies

Keywords

  • acetaminophen
  • acute liver failure
  • cerebral edema
  • fulminant hepatic failure
  • intracranial hypertension
  • intracranial pressure monitoring

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

Cite this

Outcomes and complications of intracranial pressure monitoring in acute liver failure : A retrospective cohort study. / Karvellas, Constantine J.; Fix, Oren K.; Battenhouse, Holly; Durkalski, Valerie; Sanders, Corron; Lee, William M.

In: Critical Care Medicine, Vol. 42, No. 5, 2014, p. 1157-1167.

Research output: Contribution to journalArticle

Karvellas, Constantine J. ; Fix, Oren K. ; Battenhouse, Holly ; Durkalski, Valerie ; Sanders, Corron ; Lee, William M. / Outcomes and complications of intracranial pressure monitoring in acute liver failure : A retrospective cohort study. In: Critical Care Medicine. 2014 ; Vol. 42, No. 5. pp. 1157-1167.
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abstract = "Objective: To determine if intracranial pressure monitor placement in patients with acute liver failure is associated with significant clinical outcomes. Design: Retrospective multicenter cohort study. Setting: Academic liver transplant centers comprising the U.S. Acute Liver Failure Study Group. Patients: Adult critically ill patients with acute liver failure presenting with grade III/IV hepatic encephalopathy (n = 629) prospectively enrolled between March 2004 and August 2011. Intervention: Intracranial pressure monitored (n = 140) versus nonmonitored controls (n = 489). Measurements and Main Results: Intracranial pressure monitored patients were younger than controls (35 vs 43 yr, p < 0.001) and more likely to be on renal replacement therapy (52{\%} vs 38{\%}, p = 0.003). Of 87 intracranial pressure monitored patients with detailed information, 44 (51{\%}) had evidence of intracranial hypertension (intracranial pressure > 25 mm Hg) and overall 21-day mortality was higher in patients with intracranial hypertension (43{\%} vs 23{\%}, p = 0.05). During the first 7 days, intracranial pressure monitored patients received more intracranial hypertension-directed therapies (mannitol, 56{\%} vs 21{\%}; hypertonic saline, 14{\%} vs 7{\%}; hypothermia, 24{\%} vs 10{\%}; p < 0.03 for each). Forty-one percent of intracranial pressure monitored patients received liver transplant (vs 18{\%} controls; p < 0.001). Overall 21-day mortality was similar (intracranial pressure monitored 33{\%} vs controls 38{\%}, p = 0.24). Where data were available, hemorrhagic complications were rare in intracranial pressure monitored patients (4 of 56 [7{\%}]; three died). When stratifying by acetaminophen status and adjusting for confounders, intracranial pressure monitor placement did not impact 21-day mortality in acetaminophen patients (p = 0.89). However, intracranial pressure monitor was associated with increased 21-day mortality in nonacetaminophen patients (odds ratio, ~ 3.04; p = 0.014). Conclusions: In intracranial pressure monitored patients with acute liver failure, intracranial hypertension is commonly observed. The use of intracranial pressure monitor in acetaminophen acute liver failure did not confer a significant 21-day mortality benefit, whereas in nonacetaminophen acute liver failure, it may be associated with worse outcomes. Hemorrhagic complications from intracranial pressure monitor placement were uncommon and cannot account for mortality trends. Although our results cannot conclusively confirm or refute the utility of intracranial pressure monitoring in patients with acute liver failure, patient selection and ancillary assessments of cerebral blood flow likely have a significant role. Prospective studies would be required to conclusively account for confounding by illness severity and transplant.",
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AU - Karvellas, Constantine J.

AU - Fix, Oren K.

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AU - Durkalski, Valerie

AU - Sanders, Corron

AU - Lee, William M.

PY - 2014

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N2 - Objective: To determine if intracranial pressure monitor placement in patients with acute liver failure is associated with significant clinical outcomes. Design: Retrospective multicenter cohort study. Setting: Academic liver transplant centers comprising the U.S. Acute Liver Failure Study Group. Patients: Adult critically ill patients with acute liver failure presenting with grade III/IV hepatic encephalopathy (n = 629) prospectively enrolled between March 2004 and August 2011. Intervention: Intracranial pressure monitored (n = 140) versus nonmonitored controls (n = 489). Measurements and Main Results: Intracranial pressure monitored patients were younger than controls (35 vs 43 yr, p < 0.001) and more likely to be on renal replacement therapy (52% vs 38%, p = 0.003). Of 87 intracranial pressure monitored patients with detailed information, 44 (51%) had evidence of intracranial hypertension (intracranial pressure > 25 mm Hg) and overall 21-day mortality was higher in patients with intracranial hypertension (43% vs 23%, p = 0.05). During the first 7 days, intracranial pressure monitored patients received more intracranial hypertension-directed therapies (mannitol, 56% vs 21%; hypertonic saline, 14% vs 7%; hypothermia, 24% vs 10%; p < 0.03 for each). Forty-one percent of intracranial pressure monitored patients received liver transplant (vs 18% controls; p < 0.001). Overall 21-day mortality was similar (intracranial pressure monitored 33% vs controls 38%, p = 0.24). Where data were available, hemorrhagic complications were rare in intracranial pressure monitored patients (4 of 56 [7%]; three died). When stratifying by acetaminophen status and adjusting for confounders, intracranial pressure monitor placement did not impact 21-day mortality in acetaminophen patients (p = 0.89). However, intracranial pressure monitor was associated with increased 21-day mortality in nonacetaminophen patients (odds ratio, ~ 3.04; p = 0.014). Conclusions: In intracranial pressure monitored patients with acute liver failure, intracranial hypertension is commonly observed. The use of intracranial pressure monitor in acetaminophen acute liver failure did not confer a significant 21-day mortality benefit, whereas in nonacetaminophen acute liver failure, it may be associated with worse outcomes. Hemorrhagic complications from intracranial pressure monitor placement were uncommon and cannot account for mortality trends. Although our results cannot conclusively confirm or refute the utility of intracranial pressure monitoring in patients with acute liver failure, patient selection and ancillary assessments of cerebral blood flow likely have a significant role. Prospective studies would be required to conclusively account for confounding by illness severity and transplant.

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