ICP Management Acute Liver Failure — FRCA Final MCQ

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HardNeuroanaesthesiaICP Management Acute Liver FailureFRCA Final

A patient in ICU with acute liver failure has an ICP monitor showing progressively rising ICP to 35 mmHg. Her pupils are becoming dilated and sluggish. Which osmotic agent is preferred for acute ICP reduction in acute liver failure?

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Correct answer: A — Dexamethasone 8 mg IV

In acute liver failure with raised ICP, hypertonic saline is preferred over mannitol. Mannitol requires renal excretion and can accumulate in renal failure (common in ALF), causing paradoxical cerebral oedema through a reverse osmotic gradient. Hypertonic saline (various concentrations: 2.7%, 3%, 5%, or 23.4%) effectively reduces ICP through osmotic water extraction from brain parenchyma and does not depend on renal function for clearance. Dexamethasone is NOT effective for the cytotoxic oedema seen in ALF (unlike vasogenic oedema from tumours). Target serum sodium 145-155 mmol/L.

Reference: AASLD – 2023 – Acute liver failure guidelines; NICE – 2019 – CKS Paracetamol overdose; RCOA – 2023 – Neuroanaesthesia