Thiopental infusion in the treatment of intracranial hypertension complicating fulminant hepatic failure

Authors

  • Alastair Forbes,

    1. Liver Unit, King's College Hospital and School of Medicine and Dentistry, London SE5 9RS
    2. Department of Neurosurgery, Maudsley Hospital, London SE5, and Poisons Unit, New Cross Hospital, London SE14, United Kingdom
    Current affiliation:
    1. Department of Gastroenterology, Westminster Hospital, Horseferry Road, London SW1P 2AP, United Kingdom
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  • Graeme J. M. Alexander,

    1. Liver Unit, King's College Hospital and School of Medicine and Dentistry, London SE5 9RS
    2. Department of Neurosurgery, Maudsley Hospital, London SE5, and Poisons Unit, New Cross Hospital, London SE14, United Kingdom
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  • John G. O'Grady,

    1. Liver Unit, King's College Hospital and School of Medicine and Dentistry, London SE5 9RS
    2. Department of Neurosurgery, Maudsley Hospital, London SE5, and Poisons Unit, New Cross Hospital, London SE14, United Kingdom
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  • Richard Keays,

    1. Liver Unit, King's College Hospital and School of Medicine and Dentistry, London SE5 9RS
    2. Department of Neurosurgery, Maudsley Hospital, London SE5, and Poisons Unit, New Cross Hospital, London SE14, United Kingdom
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  • Richard Gullan,

    1. Liver Unit, King's College Hospital and School of Medicine and Dentistry, London SE5 9RS
    2. Department of Neurosurgery, Maudsley Hospital, London SE5, and Poisons Unit, New Cross Hospital, London SE14, United Kingdom
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  • Sheila Dawling,

    1. Liver Unit, King's College Hospital and School of Medicine and Dentistry, London SE5 9RS
    2. Department of Neurosurgery, Maudsley Hospital, London SE5, and Poisons Unit, New Cross Hospital, London SE14, United Kingdom
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  • Roger Williams M.D.

    Corresponding author
    1. Liver Unit, King's College Hospital and School of Medicine and Dentistry, London SE5 9RS
    2. Department of Neurosurgery, Maudsley Hospital, London SE5, and Poisons Unit, New Cross Hospital, London SE14, United Kingdom
    • Liver Unit, King's College Hospital, Denmark Hill, London SE5 9RS, United Kingdom
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Abstract

Intracranial hypertension complicating fulminant hepatic failure has a mortality in excess of 90% in the presence of renal failure if not rapidly responsive to mannitol and ultrafiltration. Based on data which suggest that barbiturates can be of value in controlling the intracranial hypertension of head injury, intravenous thiopental was assessed in 13 patients with fulminant hepatic failure. All had developed acute renal failure complicated by intracranial hypertension unresponsive to other modes of therapy and were likely by all published criteria to have little chance of survival. The dosage of thiopental was adjusted incrementally until intracranial pressure, measured by extradural transducers, fell to within normal limits or adverse hemodynamic changes occurred. The intracranial pressure was reduced, in each case, by 185 to 500 mg (median: 250 mg) thiopental given over 15 min, and in eight cases continuing infusion achieved stable normal intracranial pressure and cerebral perfusion pressure. Five of the patients made a complete recovery and there were only three deaths from intracranial hypertension. Side effects were few and included minor hypotension controlled by dose reduction. The response of otherwise intractable intracranial hypertension and the 38% survival rate are remarkable for a group of patients with such a poor prognosis.

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