Moderate hypothermia with intracranial pressure monitoring as a therapeutic paradigm for the management of acute liver failure: a systematic review

To systematically review the literature and present data on the safety and efficacy of induced moderate hypothermia combined with ICP monitoring in critically ill patients with acute liver failure. We conducted a retrospective observational search of MEDLINE database using both OVID and PubMed with the following MeSH terms, Hypothermia, Induced, Brain Edema, Intracranial Hypertension (ICH), Liver failure, Acute and Liver Failure, Fulminant. We limited our search to case series involving at least three human subjects and all other clinical trials. Baseline ICP, cerebral perfusion pressure (CPP) and cerebral blood flow (CBF) as well as the response of these variables to hypothermia were recorded when available. Additional clinical and demographic data were also recorded. Five case series were identified. Pre-existing coagulopathy from liver failure was reversed by various modalities in all studies prior to insertion of ICP monitors. Induction of moderate hypothermia combined with ICP monitoring consistently improved ICP, CPP and CBF in four trials; one trial demonstrated the feasibility and effectiveness of moderate induced hypothermia as part of a protocolized strategy for the management of ICH. Limited data exist concerning the safety and efficacy of moderate hypothermia and ICP monitoring for the treatment of ICH in acute liver failure. The available evidence shows that induction of moderate hypothermia in this clinical setting is feasible and possibly efficacious. Well-designed prospective clinical trials are warranted in this challenging context, given the potential of providing a bridge to liver transplantation or even clinical recovery.