Optic nerve sheath diameter in children with acute liver failure: A prospective observational pilot study

Early detection of raised intracranial pressure (ICP) improves outcome in acute liver failure (ALF). We evaluated the feasibility of bedside, ultrasound-guided measurement of optic nerve sheath diameter (ONSD) in normal and ALF children and correlation of ONSD with grade of hepatic encephalopathy (HE), international normalized ratio (INR) and blood ammonia (BA).

Forty-one ALF and 47 healthy children (5-18 years) were prospectively enrolled and 12 hourly clinical evaluation was done. Laboratory parameters including INR and BA were recorded. ONSD was measured at admission, change in HE grade and at recovery in ALF, and once in controls.

One hundred and twenty-one ONSD measurements (ALF-74, controls-47) were taken without complications. ONSD was 4.2 (3.9-4.3), 4.4 (4.0-4.6), 5.2 (4.8-5.8) and 3.9 (3.3-4.1) mm in controls, ALF without HE, with HE and at recovery respectively. ONSD was significantly higher in ALF with HE than those without HE. ALF without HE and at recovery had ONSD similar to controls. ONSD was higher in ALF with the clinical signs of raised ICP than those without (5.4 [4.9-5.7] vs 4.6 [4.1-5.3] mm; P = .01). ONSD of 4.6 mm differentiated ALF with HE vs without HE and 5.1 mm between poor vs good non-transplant outcome with ≥80% sensitivity and specificity. ONSD positively correlated with INR (r = .53, P < .001) and BA (r = .42, P = .002).

ONSD can be safely and easily measured in ALF children and correlates with HE grade, INR and BA. Normal ONSD in children (>4 years) is <4.5 mm and value of >5.1 mm in ALF requires urgent attention.