Neurologic monitoring in children and adolescents with hepatic failure: new mechanisms and non-invasive approach.

One of the main complications of liver failure, whether acute or chronic, is the progression to Hepatic Encephalopathy (HE), cerebral edema, and, consequently, intracranial hypertension. Several mechanisms explain the progression to HE, but the key point is the impairment of the hepatic metabolism of ammonia and other toxic metabolites, causing vasogenic and cytotoxic cerebral edema and alteration of cerebral autoregulation. In the pediatric population, the diagnosis of HE is more challenging due to the difficulties in neurologic assessment in this group. Thus, the role of multimodal assessment with several monitoring methods is increasingly more important. Among these methods, invasive monitoring of ICP is increasingly being discouraged, giving way to other noninvasive assessments such as methods of assessing intracranial pressure (Brain4Care®, optic nerve sheath diameter), cerebral blood flow (transcranial doppler), and cerebral SatO2 and O2 consumption (Near-Infrared Spectroscopy, Jugular venous oxygen saturation). Thus, the multimodal evaluation of these patients has been gaining strength for better diagnosis and management of neurological conditions in pediatric patients with liver failure.