The effect of induced hypernatraemia on intracranial pressure in patients with acute liver failure: a randomised controlled clinical trial

Introduction

Acute liver failure (ALF) is a rare condition characterised by the development of encephalopathy. This is complicated by the development of cerebral oedema and intracranial hypertension (IH) in up to 80% of cases that reach grade IV encephalopathy and is a common cause of death. Preliminary work in patients with traumatic brain injury suggests that inducing and maintaining hypernatraemia can limit the severity of IH. We examined the effect of induced hypernatraemia in patients with ALF on the incidence of clinically significant IH in a prospective randomised clinical trial.

Patients and methods

Thirty patients with acute or hyperacute liver failure and grade III or IV encephalopathy were randomised. Group 1 (15 patients) received normal standard of care (SOC). Group 2 (15 patients) received SOC and hypertonic (30%) saline (HS) by infusion. The aim was to maintain serum sodium between 145 and 155 mmol/l in the HS group. The primary end point was IH. Intracranial pressure (ICP) was monitored in all patients with a subdural catheter (Camino Systems). ICP, measured continuously, was noted at 6 hourly intervals. An ICP of > 25 mmHg was considered to be clinically significant. Patient's data was examined for up to 72 hours following inclusion. Case censoring occurred following death or liver transplantation.

Results

The risk of developing clinically significant IH was greater in the control group (P = 0.04, Breslow test) over the study period (see Fig.).

Figure

Hazard function.

Conclusion

Inducing and maintaining hypernatraemia can reduce the incidence and severity of IH in patients presenting with ALF.