Comparison of terlipressin and norepinephrine on cerebral perfusion, intracranial pressure and cerebral concentrations of lactate and pyruvate in patients with acute liver failure: a microdialysis study

Introduction

Volume expansion and inotropic support with catecholamines are often insufficient to ensure adequate blood pressure and cerebral blood flow in acute liver failure (ALF). The aim of this study was to determine whether terlipressin increases cerebral perfusion and to compare the effect with that of norepinephrine (NE). Furthermore, the effect on intracranial pressure (ICP) and cerebral concentrations of lactate and pyruvate were recorded.

Methods

A retrospective study in a national four-bed liver ICU that treated 127 patients with ALF between 2001 and 2006. Thirty-eight of these patients were treated with terlipressin, and 10 patients (median age 42.5 years; range 15–66 years; five females) who also had an ICP and a microdialysis catheter placed in the cerebral cortex were included in this study. Concomitant measurements of mean arterial pressure (MAP), ICP, cerebral perfusion using transcranial Doppler sonography (V_mean) and cerebral concentrations of lactate and pyruvate were made before and after an increase in the NE infusion rate and i.v. injection of 1 mg terlipressin.

Results

NE infusion and terlipressin injection increased the MAP and V_mean (P < 0.01). Also, the ICP increased during NE infusion (P < 0.01) but not after terlipressin. The cerebral lactate concentration was unchanged during NE infusion, while it decreased after terlipressin (P < 0.05).

Conclusion

This study shows that terlipressin increases the MAP and cerebral perfusion in patients with ALF with no influence upon ICP and the cerebral concentrations of lactate and pyruvate. These findings indicate that terlipressin may be valuable, as an additive, or alternative, treatment of arterial hypotension in patients with ALF to secure brain viability.