Assessment and Management of Hepatic Coma in Children

Diagnostic Value of EEG and ONSD

EEG provides information on the severity of hepatic encephalopathy, independent of patient cooperation, and is recommended to use the 19 electrodes of the 10-20 International System for diagnostic purposes 1
Quantitative EEG analysis may improve the reliability of EEG assessment in hepatic encephalopathy, as recommended by the American Association for the Study of Liver Diseases 1, 2
Hepatic encephalopathy of increasing severity is associated with progressive slowing of the EEG, initial increase followed by a decrease in EEG amplitude, appearance of triphasic waves, and discontinuous pattern and eventually isoelectric EEG in severe cases 3
Point-of-care ultrasound can detect changes in optic nerve sheath diameter indicative of raised intracranial pressure, as suggested by the American Academy of Pediatrics 4

Serial EEG recordings help monitor treatment response and disease progression, with the American College of Gastroenterology recommending continuous EEG monitoring in comatose patients with hepatic failure 2, 7
Repeat ONSD measurements with any change in neurological status to monitor for increasing intracranial pressure, as recommended by the Society of Critical Care Medicine 4, 5
The Index of Global Cortical Function (IGCF) can provide information on cortical function in severe hepatic encephalopathy, as suggested by the European Association for the Study of the Liver 1

Cranial ultrasonography, including ONSD measurement, is the preferred initial imaging modality for diagnosing increased intracranial pressure in neonates and children, as recommended by the American Academy of Pediatrics 4, 5
ONSD measurement provides a non-invasive method to monitor for increased intracranial pressure, which may occur in severe hepatic encephalopathy, with the American College of Emergency Physicians suggesting serial measurements for monitoring disease progression 4, 5