Neurocritical care monitoring of encephalopathic children with acute liver failure: A systematic review

Abstract

Research on non‐invasive neuromonitoring specific to PALF is limited. This systematic review identifies and synthesis the existing literature on non‐invasive approaches to monitoring for neurological sequelae in patients with PALF. A series of literature searches were performed to identify all publications pertaining to five different non‐invasive neuromonitoring modalities, in line with PRISMA guidelines. Each modality was selected on the basis of its potential for direct or indirect measurement of cerebral perfusion; studies on electroencephalographic monitoring were therefore not sought. Data were recorded on study design, patient population, comparator groups, and outcomes. A preponderance of observational studies was observed, most with a small sample size. Few incorporated direct comparisons of different modalities; in particular, comparison to invasive intracranial pressure monitoring was largely lacking. The integration of current evidence is considered in the context of the clinically significant distinctions between pediatric and adult ALF, as well as the implications for planning of future investigations to best support the evidence‐based clinical care of these patients.

Non-transplant options in paediatric acute liver failure—what is new?

“…Owing to a decreased incidence of raised intracranial pressure (ICP) in ALF, recourse to invasive monitoring using intracranial bolts is decreasing. Clinicians are more commonly using non-invasive ICP monitoring methods (transcranial Doppler, optic nerve sheath assessment, tympanic membrane displacement analysis, reverse jugular venous saturation monitoring, near-infrared spectroscopy), although there is limited evidence to show that any one of these is superior to the others [6]. Standard neuroprotective measures extrapolated from paediatric trauma guidelines (head midline position, avoidance of hypercarbia and hyponatremia, age-dependent cerebral perfusion pressure, and avoidance of triggers of raised ICP) are followed [7].…”

“…5 Institute of Integrative Biology of the Cell, CNRS, CEA, Paris Saclay University, Gif-sur-Yvette, France. 6 FHU Sepsis, AP-HP, Paris Saclay University, Inserm, Le Kremlin-Bicêtre, France.…”

Outbreak of hepatitis in children: clinical course of children with acute liver failure admitted to the intensive care unit

“…The majority of children who develop hepatitis can be managed locally with expert advice from tertiary liver centres. However, good outcomes both with and without transplant can be achieved in those who progress to acute liver failure (ALF) by dedicated liver intensive care including early referral to liver transplant centres, early recognition of neurologic deterioration, early institution of high-volume extracorporeal therapies, close neuro-monitoring and neuroprotection and working in close collaboration with hepatology and transplant colleagues to decide medical treatments and timing of listing of these patients [4,5]. As our understanding of the mechanism underpinning these cases (especially if immune-mediated) become clear, it might be possible to manage these children with intensive care therapies in conjunction with steroids and other immunomodulatory drugs.…”

Transcranial Doppler Ultrasonography in Children With Acute Liver Failure and Severe Hepatic Encephalopathy

“…Acute liver failure (ALF) may be associated with the development of brain edema and raised intracranial pressure (ICP) with severe consequences (1–3). However, raised ICP is difficult to assess noninvasively, and placement of an invasive ICP monitor in the ALF patient carries substantial risk of intracranial hemorrhage (4). In adult ALF patients, but not children (4), noninvasive measurement of vascular transcranial Doppler (TCD) of arterial flow is used as a dynamic measure of cerebral perfusion and components of the flow velocity signal show a close correlation with level of ICP (5, 6).…”

“…However, raised ICP is difficult to assess noninvasively, and placement of an invasive ICP monitor in the ALF patient carries substantial risk of intracranial hemorrhage (4). In adult ALF patients, but not children (4), noninvasive measurement of vascular transcranial Doppler (TCD) of arterial flow is used as a dynamic measure of cerebral perfusion and components of the flow velocity signal show a close correlation with level of ICP (5, 6). It is also possible that TCD findings may be related to patient outcome (7).…”