TABLE 2.
Management of intracranial pressure in patients with ALF
| Therapeutic maneuver | Goal | Comments | Reference |
|---|---|---|---|
| Prophylaxis against cerebral edema | |||
| Elevate head to 30 degrees; neck in neutral position | Improve cerebral venous return | ||
| Induced hypernatremia | Serum sodium 145–155 mmol/L | HTS or CRRT | 116 |
| Early CRRT | Ammonia lowering; correct hypo-osmolality | No anticoagulation, citrate and heparin acceptable | 117 |
| Prophylactic Hypothermiaa | 35°C–36°C | Allow spontaneous hypothermia | 118 a |
| Respiratory alkalosis | PCO2 35–40 mm Hg (avoid excess hypocarbia or hypercarbia) | Allow spontaneous hyperventilation if pCO2 < 35 mm Hg | 119 |
| Treatment of established cerebral edema | |||
| Mannitol boluses | ICP < 25 mm Hg | 0.5–1.0 g/kg body weight if patient making urine | 120 |
| Hypertonic saline boluses | ICP < 25 mm Hg | Many regimens | 119 |
| Vasopressors | MAP > 65 mm Hg CPP > 60 mm Hg |
Norepinephrine ± vasopressin |
119 |
| Therapeutic hypothermia | 32°C–34°C | Cooling blankets, extracorporeal circuits or external cooling device (eg, Arctic Sun) | 121 |
| Deeper sedation | Coma | Barbiturates, propofol | 122 |
Note: Treatment of established cerebral edema should include all of the prophylactic measures noted.
a
Randomized, controlled trial of prophylactic management under hypothermic versus normothermic conditions was negative.
Abbreviations: CPP, cerebral perfusion pressure; CRRT, continuous renal replacement therapy; HTS, hypertonic saline; ICP, intracranial pressure; MAP, mean arterial pressure.