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Neurological monitoring and sedation protocols in the Liver Intensive Care Unit

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Abstract

Patients with liver disease often have alteration of neurological status which requires admission to an intensive care unit. Patients with acute liver failure (ALF), acute-on-chronic liver failure (ACLF) and rarely cirrhosis are at risk of cerebral edema. These patients require prompt assessment of neurological status including assessment of intra-cranial pressure (ICP) and monitoring metabolic parameters like arterial/venous ammonia levels, serum creatinine and serum electrolytes so that timely specific therapy for raised ICP can be instituted to prevent permanent neurological dysfunction. The overall aims of neuromonitoring and sedation protocols in a liver intensive care unit are to identify the level of multifactorial metabolic encephalopathy, individualize sedation and analgesia requirements for patients on mechanical ventilation, institute specific therapy to correct the neurological insult in ALF and ACLF, provide clear physiological data for guided therapy of drugs like muscle relaxants, antiepileptics, and cerebral edema reducing agents, and assist with overall prognostication. In this review article we will outline the clinical scenarios related to liver disease requiring intensive care and neuromonitoring, current techniques of neurological assessment, sedation protocols and point of care tests which enable the treating physician and intensivist guide therapy for raised ICP.

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Abbreviations

CBF:

cerebral blood flow

CPP:

cerebral perfusion pressure

CT:

computed tomography

EEG:

electroencephalography

GCS:

Glasgow coma scale

ICP:

intracranial pressure

MAP:

mean arterial pressure

MRI:

magnetic resonance imaging

PAV:

percent α variability

PbtO2 :

Partial pressure of O2 in brain tissue

qEEG:

quantitative EEG

SjO2 :

jugular venous oxygen saturation

SSEP:

somatosensory evoked potential

TBI:

traumatic brain injury

TCD:

transcranial doppler

TDP:

thermal diffusion probe

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Funding

Partially supported by a research grant by the Department of Health Research, Indian Council of Medical Research awarded to MP. (GIA/2019/000639/PRCGIA)

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Authors and Affiliations

  1. Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India

    Rohit Mehtani & Madhumita Premkumar

  2. Department of Anesthesiology and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India

    Shankey Garg, Kamal Kajal & Shiv Lal Soni

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  1. Rohit Mehtani
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  2. Shankey Garg
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  3. Kamal Kajal
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  4. Shiv Lal Soni
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  5. Madhumita Premkumar
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Contributions

MP is the article guarantor. RM and MP performed the literature search. Compilation and initial drafting by RM, SG and MP. Figures by RM and MP. Tables by RM and SG. Final editing and critical revision by RM, SG, KK, SLS and MP. All authors approved the final draft.

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Correspondence to Madhumita Premkumar.

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Highlights

• Monitoring of cerebral function should be done in all comatose patients with liver disease.

• Current protocols are centered around clinical assessment using standardized scores like West Haven Classification as Glasgow Coma Scale in not sensitive in patients with cirrhosis and liver failure due to competing issues of hepatic encephalopathy, raised intracranial pressure and metabolic encephalopathy.

• The goals of neuromonitoring in Liver intensive care unit are to identify worsening neurological function, raised intracranial pressure and secondary insults like sepsis and dyselectrolytemia and to provide real time physiological data to guide and individualize therapy.

• In absence of ‘gold standard’ brain monitor specific to liver disease a combination of monitoring techniques may provide better insight into cerebral dysfunction.

• Sedation protocols in patients with liver disease are not yet standardized and an individualized approach is preferred.

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Mehtani, R., Garg, S., Kajal, K. et al. Neurological monitoring and sedation protocols in the Liver Intensive Care Unit. Metab Brain Dis 37, 1291–1307 (2022). https://doi.org/10.1007/s11011-022-00986-7

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