How is intracranial hypertension treated in patients with acute liver failure?

Updated: Jun 13, 2019
  • Author: Gagan K Sood, MD; Chief Editor: BS Anand, MD  more...
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Answer

Management of intracranial hypertension

ICH is managed initially with the use of mannitol. Osmotic diuresis with intravenous (IV) mannitol is effective in the short term in decreasing cerebral edema. Administration of IV mannitol (in a bolus dose of 0.5-1 g/kg or 50-100 g) is recommended to treat ICH in acute liver failure. The dose may be repeated once or twice, as needed, provided that serum osmolality has not exceeded 320 mOsm/L. Volume overload is a risk with mannitol use in patients with renal impairment and may necessitate the use of dialysis to remove excess fluid.

If life-threatening ICH is not controlled with mannitol infusion and other general management as outlined above, hyperventilation may be instituted temporarily in an attempt to acutely lower the ICP and to prevent impending herniation. Hyperventilation to reduce the partial pressure of carbon dioxide in the blood (PaCO2) to 25-30 mm Hg can quickly lower ICP via vasoconstriction, causing decreased cerebral blood flow, but this effect is short lived.

Other therapies used to decrease ICH but not routinely recommended may be considered in refractory ICH. These include hypertonic saline, barbiturates, and hypothermia.

A controlled trial of administration of 30% hypertonic saline, 5-20 mL/hour, to maintain serum sodium levels of 145-155 mmol/L in patients with acute liver failure and severe encephalopathy suggested that induction and maintenance of hypernatremia may be used to prevent the rise in ICP values. [42]


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