Invasive Monitoring in Acute Liver Failure

Acute liver failure (ALF) is a rapidly progressive condition marked by severe hepatic dysfunction, coagulopathy, and high short-term mortality driven largely by cerebral edema and circulatory collapse. Because neurological deterioration and hemodynamic instability can evolve unpredictably and interact dynamically, continuous physiologic monitoring is central to management. Invasive intracranial pressure (ICP) monitoring provides the most direct assessment of intracranial dynamics and supports cerebral perfusion pressure-oriented therapy; however, its routine use remains controversial due to limited outcome data and substantial hemorrhagic risk in the setting of severe coagulopathy. Current evidence, largely observational, favors a selective approach to ICP monitoring in patients with advanced encephalopathy or rapidly worsening neurological status, particularly in experienced centers. Noninvasive adjuncts, including optic nerve sheath ultrasound, transcranial Doppler, and electroencephalography, offer complementary information but do not replace direct ICP measurement. Hemodynamic monitoring, anchored by continuous arterial pressure measurement and central venous access, is indispensable for maintaining systemic perfusion and protecting cerebral blood flow. Advanced cardiac output monitoring and echocardiography further enable individualized fluid and vasopressor strategies. Overall, a multimodal, physiology-driven monitoring framework that integrates neurological and circulatory assessment is essential to optimize outcomes in ALF.