Liver transplantation

Noninvasive estimation of raised intracranial pressure using ocular ultrasonography in liver transplant recipients with acute liver failure -A report of two cases-

Authors: Kim YK, Seo H, Yu J, Hwang GS.

Intracranial pressure (ICP) monitoring is an important issue for liver transplant recipients, since increased ICP is associated with advanced hepatic encephalopathy or graft reperfusion during liver transplantation. Invasive monitoring of ICP is known as a gold standard method, but it can provoke bleeding and infection; thus, its use is a controversial issue. Studies have shown that optic nerve sheath diameter > 5 mm by ocular ultrasonography is useful for evaluating ICP > 20 mmHg noninvasively in many clinical settings. In this case report, we present experiences of using ocular ultrasound as a diagnostic tool that could detect changes in ICP noninvasively during liver transplantation.

Perioperative estimation of intracranial pressure using optic nerve sheath diameter during liver transplantation

Authors: Krishnamoorthy V, Beckmann K, Mueller M, Sharma D, Vavilala M.

Elevation in intracranial pressure (ICP) secondary to cerebral edema is a major contributor to morbidity and mortality in acute liver failure. In addition, invasive intracranial pressure monitoring in this setting is controversial, as coagulopathy predisposes to hemorrhagic complications. In this case report, the authors describe the novel use on optic nerve sheath diameter (ONSD) monitoring as a non-invasive modality to monitor for acute elevation in ICP in this setting. The merits of rapidly evolving ultrasound technologies may serve as a safe method to improve patient care in this setting. © 2012 American Association for the Study of Liver Diseases.
Copyright © 2012 American Association for the Study of Liver Diseases.

Liver transplantation results in complete neurologic recovery from malignant hypertension secondary to fulminant hepatic failure: A case report

Authors: Tsoulfas G, Elias N, Sandberg WS, Ko DS, Kawai T, Cosimi AB, Tsitsopoulos PP, Agorastou P, Hertl M.

Background: Uncontrolled intracranial hypertension can lead to cerebral herniation and death in patients with acute liver failure. Case Report: A 26-year-old female was admitted for acute liver failure following inadvertent acetaminophen overdose. The pH on admission was 6.9. Her neurologic status precipitously deteriorated and she was listed for liver transplantation. An intracranial pressure (ICP) monitoring catheter was inserted, which revealed a pressure >60 mmHg. After neurointensive care treatment, ICP was lowered and an emergency left lobe living donor liver transplant was performed. Intraoperative management of the ICP, which rose to 80mmHg during the explant phase, was achieved by therapy with barbiturates and hypothermia. After surgery, hepatic function improved initially, but 7 days post transplantation the graft showed signs of acute failure. The pathology report of a liver biopsy suggested acute rejection and liver retransplantation using a deceased donor liver was then carried out. The postoperative course was uneventful and the patient recovered completely without any residual neurologic deficits. Conclusions: This case states that favourable outcomes can result from sub-optimal starting points, and that the human brain has the ability to overcome extremely adverse conditions. Critical in this effort is the role of proper neuromonitoring which helps implement the appropriate treatment measures.

Emergent, Controlled Lumbar Drainage for Intracranial Pressure Monitoring During Orthotopic Liver Transplantation

Authors: C. Joseph Bacani, W. D. Freeman, Rachel A. Di Trapani, Juan C. Canabal, Lisa Arasi, Timothy Shine and Darrin L. Willingham.

Background:  Measurement of intracranial pressure (ICP) is recommended in comatose acute liver failure (ALF) patients due to risk of rapid global cerebral edema. External ventricular drains (EVD) can be placed to drain cerebrospinal fluid and monitor ICP simultaneously although this remains controversial in the neurosurgical community given the risk of hemorrhagic complications. We describe a patient with ALF and global cerebral edema whose EVD failed immediately before orthotopic liver transplantation (OLT) in which a lumbar drain (LD) was used temporarily to monitor ICP.
Methods:  We describe a 36 year old patient with ALF and brain edema from acetaminophen overdose who had an EVD placed for ICP monitoring and management. The EVD failed repeatedly (i.e., lost CSF drainage and ICP waveform) despite several saline irrigations and three doses intraventricular tissue plasminogen activator (1 mg) in the hours that immediately preceded her planned emergency OLT. An LD was placed emergently and controlled cerebrospinal fluid (CSF) drainage and ICP measurement was performed by setting the LD at 20 mmHg and leveling at the ear level (foramen of Monro). The LD was removed once the EVD flow was re-established post-OLT.
Results: The EVD and LD ICP measurements were reported to be the same just prior to removing the LD.
Conclusions: Controlled CSF drainage using a lumbar drain can be used to monitor ICP when leveled at the foramen of Monro if EVD failure occurs perioperatively. The LD can temporarily guide ICP management until the EVD flow can be re-established after OLT.

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