Advantage of intracranial pressure (ICP) monitoring for liver transplantation with fulminant hepatic failure

Liver transplantation is becoming an accepted treatment for fulminant hepatic failure, but indication for liver transplantation is still controversial. Cerebral edema and intracranial hypertension accompanied by advanced encephalopathy are fatal complications influencing the patient's survival. We used ICP monitoring to try to manage such complications. From July 1985 to May 1991, we performed orthotopic liver transplantation in 45 patients with fulminant hepatic failure. Indications for liver transplantation were non-ii non-B hepatitis (24), hepatitis A (5), hepatitis B (5), tyrosinemia (4), drug induced hepatic failure (4), recurrence of hepatitis B (1) and others (2). Actuarial survival rates at one month, three months, six months, one year and three years were 75.0%, 70.5%, 63.5%, 63.5%, and 59.3%, respectively. The Ladd epidural pressure monitor for monitoring ICP was placed in 43 patients including 28 transplanted patients. In phase I, we selected patients for liver transplantation regardless of ICP data. Of these, none of the 6 with cerebral perfusion pressure (CPP) below 40 mmHg sustained for more than 2hours avoided cerebral death. All 6 patients who experienced full neurologic recovery maintained CPP of more than 50mmHg at all times. From the phase I study, we confirmed that we should maintain ICP below 20mmHg or CPP above 50mmHg during the perioperative period. Based on these data, in phase II we evaluated patients for liver transplantation usinig ICP monitor data. Of these, seven patients were omitted from transplantation because of sustained high ICP or low CPP. Three patients who maintained low ICP or high CPP recovered and no longer required liver transplantation. In transplanted patients, all patients who had severe neurological injury and didn't recover had experienced sustained high ICP or low CPP. All patients who recovered normal neurological function maintained relatively normal ICP or excellent CPP. Neither computed tomography nor electroencephalography could predict mortality or neurological recovery. ICP monitoring enabled us to manage patients with cerebral edema effectively and should become a good indicator for performing liver transplantation. We also confirmed that ICP monitoring can predict neurological recovery. Such monitoring enables us to perform liver transplantation safely with effective perioperative support and enhances liver transplantation as a definite treatment for fulminant hepatic failure.