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Wu M, Zhang H, Huang Y, Wu W, Huang J, Yan D. Efficiency of Double Plasma Molecular Absorption System on the Acute Severe Cholestatic Hepatitis. Blood Purif 2021; 50:876-882. [PMID: 33508826 DOI: 10.1159/000513161] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 11/17/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cholestasis may lead to hepatic cirrhosis and a longer hospital stay. A part of the patients with cholestasis requires liver transplantation. However, most of the treatment efficiency of cholestatic hepatitis (CH) is not satisfactory. For the patients with severe CH after artificial liver support, there was a lack of systemic evaluation on the treatment efficiency of double plasma molecular absorption system (DPMAS) for acute severe CH. OBJECTIVE We aim to investigate the treatment efficiency of DPMAS on acute severe CH. METHODS This retrospective study involved 309 cases diagnosed with acute severe CH admitted to the First Affiliated Hospital, Zhejiang University. We compared the prognosis of patients received standard medical therapy (SMT) and SMT + DPMAS. Besides, the effects of DPMAS on total bilirubin (TBIL) and prothrombin time (PT) were investigated. RESULTS DPMAS could significantly reduce the requirements for liver transplantation in the CH patients. After DPMAS therapy, significant decline was noticed in the TBIL, direct bilirubin (DBIL), total bile acid, and cholesterol. The baseline ratio of neutrophil showed significant elevation in the patients received 4 or more DPMAS compared with those received less DPMAS. CONCLUSIONS DPMAS could significantly eliminate the necessity of liver transplantation. The artificial liver support system should be conducted to bring down the bilirubin level and the ratio of cases with severe conditions. In general, DPMAS should be preferred as an artificial liver support therapy for the patients with acute severe CH.
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Affiliation(s)
- Meimei Wu
- Department of Hepatobiliary Medicine, Fuzhou Second Hospital Affiliated to Xiamen University, Xiamen, China
| | - Huafeng Zhang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yandi Huang
- Department of Laboratory Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Wu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianrong Huang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dong Yan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China,
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2
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Acute Fatty Liver of Pregnancy: Pathophysiology, Anesthetic Implications, and Obstetrical Management. Anesthesiology 2020; 130:446-461. [PMID: 30707120 DOI: 10.1097/aln.0000000000002597] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
A narrative review of the pathophysiology, diagnosis, management, delivery implications, obstetric anesthesia care, and potential critical care needs in patients presenting with acute fatty liver of pregnancy.
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3
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Bonavia A, Pachuski J, Bezinover D. Perioperative Anesthetic Management of Patients Having Liver Transplantation for Uncommon Conditions. Semin Cardiothorac Vasc Anesth 2017; 22:197-210. [PMID: 28922972 DOI: 10.1177/1089253217732129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This review focuses on the perioperative anesthetic management of patients having liver transplantation (LT) performed for several uncommon indications or in combination with rare pathology. Conditions discussed in the article include Alagille syndrome, hypertrophic cardiomyopathy, Gilbert's syndrome, porphyria, Wilson's disease, and Budd-Chiari syndrome. In comparison to other indications, LT in these settings is infrequent because of the low incidence of these pathologies. Most of these conditions (with the exception of Gilbert syndrome) are associated with a high probability of significant perioperative complications and increased mortality and morbidity. Experience in management of these unusual conditions is only gained over time. Developing clinical pathways for patients with these conditions should result in outcomes similar to LT performed for more common indications.
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Affiliation(s)
- Anthony Bonavia
- 1 Penn State Milton S Hershey Medical Center, Hershey, PA, USA
| | - Justin Pachuski
- 1 Penn State Milton S Hershey Medical Center, Hershey, PA, USA
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4
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Liver transplantation for acute liver failure. Cir Esp 2017; 95:181-189. [PMID: 28433231 DOI: 10.1016/j.ciresp.2017.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 01/11/2017] [Accepted: 01/19/2017] [Indexed: 12/16/2022]
Abstract
Before liver transplantation became widely applicable as a treatment option, the mortality rate for acute liver failure was as high as 85%. Today, acute liver failure is a relatively common transplant indication in some settings, but the results of liver transplantation in this context appear to be worse than those for chronic forms of liver disease. In this review, we discuss the indications and contraindications for urgent liver transplantation. In particular, we consider the roles of auxiliary, ABO-incompatible, and urgent living donor liver transplantation and address the management of a «status 1» patient with total hepatectomy and portocaval shunt for toxic liver syndrome.
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5
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The efficacy and safety of entecavir in patients with chronic hepatitis B- associated liver failure: a meta-analysis. Ann Hepatol 2015. [DOI: 10.1016/s1665-2681(19)30776-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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6
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Anaesthetic and Perioperative Management for Liver Transplantation. ABDOMINAL SOLID ORGAN TRANSPLANTATION 2015. [PMCID: PMC7124066 DOI: 10.1007/978-3-319-16997-2_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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7
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Kiamanesh D, Rumley J, Moitra VK. Monitoring and managing hepatic disease in anaesthesia. Br J Anaesth 2014; 111 Suppl 1:i50-61. [PMID: 24335399 DOI: 10.1093/bja/aet378] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Patients with liver disease have multisystem organ dysfunction that leads to physiological perturbations ranging from hyperbilirubinaemia of no clinical consequence to severe coagulopathy and metabolic disarray. Patient-specific risk factors, clinical scoring systems, and surgical procedures stratify perioperative risk for these patients. The anaesthetic management of patients with hepatic dysfunction involves consideration of impaired drug metabolism, hyperdynamic circulation, perioperative hypoxaemia, bleeding, thrombosis, and hepatic encephalopathy.
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Affiliation(s)
- D Kiamanesh
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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8
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Ates M, Hatipoglu S, Dirican A, Isik B, Ince V, Yilmaz M, Aydin C, Ara C, Kayaalp C, Yilmaz S. Right-lobe living-donor liver transplantation in adult patients with acute liver failure. Transplant Proc 2014; 45:1948-52. [PMID: 23769080 DOI: 10.1016/j.transproceed.2012.10.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 10/30/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Right-lobe living-donor liver transplantation (RLDLT) is an excellent option to reduce donor shortages for adult patients with acute liver failure (ALF). The aim of this study was to evaluate the etiologies and outcomes of 30 consecutive adult patients who underwent emergency RLDLT for ALF. METHODS Between January 2007 and September 2011, we examined data from medical records of patients with ALF who underwent RLDLT. RESULTS Their mean age was 32.2 ± 13.05 years. The etiologies of ALF were acute hepatitis B (n = 11; 36.6%), hepatitis A (n = 4; 13.3%), drug intoxication (n = 4; 13.3%), pregnancy (n = 2; 6.7%), hepatitis B with pregnancy (n = 1; 3.3%), mushroom intoxication (n = 1; 3.3%), and unknown (n = 7; 23.3%). The mean hepatic coma grade (Model for End-Stage Liver Disease score) was 34.13 ± 8.72. The 43 (48.7%) postoperative complications were minor (grades I-II) and 44 (51.3%) were major (grades III-V). Reoperation was required in 14 of 30 (47%) recipients (grades IIIb-IVa). Deaths occurred owing to pulmonary (n = 2), cardiac (n = 1), septic (n = 2), or encephalopathic (n = 4) complications. The mean durations of intensive care unit stay and postoperative hospitalization were 3.2 ± 2.3 and 29.5 ± 23 days, respectively. The survival rate was 70%. The mean follow-up duration was 305 days (range, 1-1582). CONCLUSION Liver transplantation is potentially the only curative modality, markedly improving the prognosis of patients with ALF. The interval between ALF onset and death is short and crucial because of the rapid, progressive multiorgan failure. Thus, RLDLT should be considered to be a life-saving procedure for adult patients with ALF, requiring quicker access to a deceased-donor liver graft and a short ischemia time.
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Affiliation(s)
- M Ates
- Department of General Surgery, Inonu University, School of Medicine, Malatya, Turkey.
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9
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Sivilotti MLA, Juurlink DN, Garland JS, Lenga I, Poley R, Hanly LN, Thompson M. Antidote removal during haemodialysis for massive acetaminophen overdose. Clin Toxicol (Phila) 2013; 51:855-63. [PMID: 24134534 DOI: 10.3109/15563650.2013.844824] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Haemodialysis is sometimes used for patients with massive acetaminophen overdose when signs of "mitochondrial paralysis" (lactic acidosis, altered mental status, hypothermia and hyperglycaemia) are present. The role of haemodialysis is debated, in part because the evidence base is weak and the endogenous clearance of acetaminophen is high. There is also concern because the antidote acetylcysteine is also dialyzable. We prospectively measured serum acetylcysteine concentrations during haemodialysis in three such cases. CASE DETAILS Three adults each presented comatose and acidemic 10 to ~18 h after ingesting > 1000mg/kg of acetaminophen. Two were hypothermic and hyperglycaemic. Serum lactate concentrations ranged from 7 mM to 12.5 mM. All three were intubated, and initial acetaminophen concentrations were as high as 5980 μM (900 μg/mL). An intravenous loading dose of 150 mg/kg acetylcysteine was initiated between 10.8 and ~18 h post ingestion, and additional doses were empirically administered during haemodialysis to compensate for possible antidote removal. A single run of 3-4 h of haemodialysis removed 10-20 g of acetaminophen (48-80% of remaining body burden), reduced serum acetaminophen concentrations by 56-84% (total clearance 3.4-7.8 mL/kg/min), accelerated native acetaminophen clearance (mean elimination half-life 580 min pre-dialysis, 120 min during and 340 min post-dialysis) and corrected acidemia. Extraction ratios of acetylcysteine across the dialysis circuit ranged from 73% to 87% (dialysance 3.0 to 5.3 mL/kg/min). All three patients recovered fully, and none developed coagulopathy or other signs of liver failure. DISCUSSION When massive acetaminophen ingestion is accompanied by coma and lactic acidosis, emergency haemodialysis can result in rapid biochemical improvement. As expected, haemodialysis more than doubles the clearance of both acetaminophen and acetylcysteine. Because acetylcysteine dosing is largely empirical, we recommend doubling the dose during haemodialysis, with an additional half-load when dialysis exceeds 6 h.
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Affiliation(s)
- M L A Sivilotti
- Department of Emergency Medicine, Queen's University , Kingston, ON , Canada
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10
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Lee S, Jung HS, Choi JH, Lee J, Hong SH, Lee SH, Park CS. Perioperative risk factors for prolonged mechanical ventilation after liver transplantation due to acute liver failure. Korean J Anesthesiol 2013; 65:228-36. [PMID: 24101957 PMCID: PMC3790034 DOI: 10.4097/kjae.2013.65.3.228] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 03/26/2013] [Accepted: 04/02/2013] [Indexed: 12/28/2022] Open
Abstract
Background Acute liver failure (ALF) is a rapidly progressing and fatal disease for which liver transplantation (LT) is the only treatment. Posttransplant mechanical ventilation tends to be more prolonged in patients with ALF than in other LT patients. The present study examined the clinical effects of prolonged posttransplant mechanical ventilation (PMV), and identified risk factors for PMV following LT for ALF. Methods We reviewed data of patients undergoing LT for ALF between January 2005 and June 2011. After grouping patients according to administration of PMV (≥ 24 h), donor and recipient perioperative variables were compared between the groups with and without PMV. Potentially significant factors (P < 0.1) from the univariate intergroup comparison were entered into a multivariate logistic regression to establish a predictive model for PMV. Results Twenty-four (25.3%) of 95 patients with ALF who received PMV had a higher mortality rate (29.2% vs 11.3%, P = 0.038) and longer intensive care unit stay (12.9 ± 10.4 vs 7.1 ± 2.7 days, P = 0.012) than patients without PMV. The intergroup comparisons revealed worse preoperative hepatic conditions, more supportive therapy, and more intraoperative fluctuations in vital signs and less urine output in the with- compared with the without-PMV group. The multivariate analysis revealed that preoperative hepatic encephalopathy (≥ grade III), intraoperative blood pressure fluctuation, and oliguria (< 0.5 ml/kg/h) were independent risk factors for PMV. Conclusions PMV was associated with deleterious outcomes. Besides care for known risk factors including hepatic encephalopathy, meticulous attention to managing intraoperative hemodynamic circulatory status is required to avoid PMV and improve the posttransplant prognosis in ALF patients.
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Affiliation(s)
- Serin Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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11
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Jun IG, Shin WJ, Park YS, Song JG, Kim YK, Hwang GS. Factors affecting intraoperative changes in regional cerebral oxygen saturation in patients undergoing liver transplantation. Transplant Proc 2013; 45:245-50. [PMID: 23375309 DOI: 10.1016/j.transproceed.2012.10.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 10/09/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Regional oxygen saturation (rSO(2)) is a sensitive marker of cerebral hypoperfusion during liver transplantation. However, bilirubin absorbs near-infrared light, resulting in falsely low rSO(2) values. We sought to determine whether rSO(2) values vary in response to bilirubin concentrations during liver transplantation and to assess whether rSO(2) changes were associated with factors reflecting cerebral oxygen delivery in patients with hyperbilirubinemia. METHODS Measurements of rSO(2) values continuous cardiac output (CO), mean arterial pressure, central venous pressure, body temperature, arterial blood gas analysis, and laboratory parameters were simultaneously performed at 1 hour after the surgical incision (baseline) and at 3 predetermined times during the anhepatic and neohepatic phases in 95 end-stage liver disease patients including 67 males of Child A/B/C/29/29/37 categories respectively. Relationships between changes in parameters were evaluated by correlation and multivariate regression analyses. RESULTS The 273 measurements revealed changes in rSO(2) (range, -18% to 40%) to correlate significantly with alterations in hemoglobin (Hb), serum glucose, lactate, prothrombin time, pH, partial arterial CO(2) pressure (PaCO(2)), and CO, but not with serum total bilirubin (TB). Multivariate linear regression analysis revealed that changes in Hb, CO, PaCO(2), and pH were independent of rSO(2) changes during liver transplantation. CONCLUSIONS Our findings showed that rSO(2) changes were independently associated with factors reflecting cerebral oxygen delivery, such as Hb, CO, PaCO(2), and pH, whereas rSO(2) values did not correlate with changes in bilirubin concentrations, indicating that rSO(2) changes reveal cerebral oxygen balance regardless of TB levels among patients undergoing liver transplantation.
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Affiliation(s)
- I-G Jun
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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12
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Intraoperative predictors of short-term mortality in living donor liver transplantation due to acute liver failure. Transplant Proc 2013; 45:236-40. [PMID: 23375307 DOI: 10.1016/j.transproceed.2012.06.077] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 05/23/2012] [Accepted: 06/19/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Acute liver failure (ALF) is a rare and fatal disease with rapidly deteriorating clinical features. Many predictive models for ALF outcomes have been tested, but none have been adopted as definitive guidelines for prognosis because of inconsistencies in accuracy. Most prognostic models for ALF are based on preoperative patient conditions, thus ignoring various specific intraoperative features relevant to postoperative outcomes. We investigated whether intraoperative factors predicted short-term mortality due to ALF in living donor liver transplantations (LDLT). METHODS We retrospectively collected intraoperative data, including surgical time, fluctuations in mean blood pressure (MBP) and heart rate, mean pulmonary arterial pressure (PAP), central venous pressure (CVP), urine output, laboratory data, oxygen indices (PaO(2)/FiO(2)), administered drugs, and transfusion of packed red blood cells (PRBCs) from 101 patients with ALF who underwent LDLT. After simple relationships of individual intraoperative variables with 1-month posttransplant mortality were analyzed, we examined potentially significant intraoperative variables (P < .10) by a multivariate adjustment process with preoperative indicators of ALF prognosis. RESULTS Intraoperative MBP fluctuations, first mean PAP and CVP, last oxygen index, administered calcium chloride, and PRBC transfusion showed individual associations with posttransplant mortality of ALF patients (P < .05). After multivariate adjustment, PRBC transfusion of ≥ 10 pints (odds ratio 4.73; 95% confidence interval [CI] 1.06-21.16) and MBP fluctuations (odds ratio 1.26; 95% CI 1.00-1.58) were identified to be independent predictors of 1-month posttransplant mortality, together with preoperative factors, including severe hepatic encephalopathy, and a Model for End-stage Liver Disease score ≥ 30 points (area under the curve 0.82, P < .001). CONCLUSION MBP fluctuations and large blood transfusions were intraoperative predictors of short-term mortality after LDLT due to ALF. Increased attention to intraoperative manifestations should provide valuable prognostic information for ALF.
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13th Asia-Pacific Congress of Clinical Microbiology and Infection Consensus Guidelines for diagnosis and treatment of liver failure. Hepatobiliary Pancreat Dis Int 2013; 12:346-54. [PMID: 23924491 DOI: 10.1016/s1499-3872(13)60055-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
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- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
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14
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Kim YK, Seo H, Yu J, Hwang GS. Noninvasive estimation of raised intracranial pressure using ocular ultrasonography in liver transplant recipients with acute liver failure -A report of two cases-. Korean J Anesthesiol 2013; 64:451-5. [PMID: 23741570 PMCID: PMC3668109 DOI: 10.4097/kjae.2013.64.5.451] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 08/09/2012] [Accepted: 08/10/2012] [Indexed: 12/16/2022] Open
Abstract
Intracranial pressure (ICP) monitoring is an important issue for liver transplant recipients, since increased ICP is associated with advanced hepatic encephalopathy or graft reperfusion during liver transplantation. Invasive monitoring of ICP is known as a gold standard method, but it can provoke bleeding and infection; thus, its use is a controversial issue. Studies have shown that optic nerve sheath diameter > 5 mm by ocular ultrasonography is useful for evaluating ICP > 20 mmHg noninvasively in many clinical settings. In this case report, we present experiences of using ocular ultrasound as a diagnostic tool that could detect changes in ICP noninvasively during liver transplantation.
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Affiliation(s)
- Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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15
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Abstract
Acute liver failure (ALF) is a condition wherein the previously healthy liver rapidly deteriorates, resulting in jaundice, encephalopathy, and coagulopathy. There are approximately 2000 cases per year of ALF in the United States. Viral causes (fulminant viral hepatitis [FVH]) are the predominant cause of ALF in developing countries. Given the ease of spread of viral hepatitis and the high morbidity and mortality associated with ALF, a systematic approach to the diagnosis and treatment of FVH is required. In this review, the authors describe the viral causes of ALF and review the intensive care unit management of patients with FVH.
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MESH Headings
- Acetylcysteine/therapeutic use
- Adult
- Brain Edema/etiology
- Brain Edema/virology
- Developing Countries
- Female
- Hepatectomy
- Hepatitis, Viral, Human/complications
- Hepatitis, Viral, Human/drug therapy
- Hepatitis, Viral, Human/prevention & control
- Herpesviridae/pathogenicity
- Humans
- Hypothermia, Induced/adverse effects
- Hypothermia, Induced/standards
- Immunocompromised Host
- Intensive Care Units
- Intubation, Intratracheal
- Liver Failure, Acute/etiology
- Liver Failure, Acute/therapy
- Liver Failure, Acute/virology
- Liver Transplantation
- Pregnancy
- Pregnancy Complications, Infectious/virology
- Prognosis
- Viral Hepatitis Vaccines/administration & dosage
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Affiliation(s)
- Saumya Jayakumar
- Faculty of Medicine and Dentistry, Division of Gastroenterology, University of Calgary, TRW Building, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
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Staufer K, Trauner M, Fuhrmann V. Akutes Leberversagen. WIENER KLINISCHE WOCHENSCHRIFT. EDUCATION 2012; 7:59-76. [PMID: 32288850 PMCID: PMC7101669 DOI: 10.1007/s11812-012-0051-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Katharina Staufer
- Klinische Abteilung für Gastroenterologie und Hepatologie, Intensivstation 13h1, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Michael Trauner
- Klinische Abteilung für Gastroenterologie und Hepatologie, Intensivstation 13h1, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Valentin Fuhrmann
- Klinische Abteilung für Gastroenterologie und Hepatologie, Intensivstation 13h1, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
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Continuous cerebral blood flow autoregulation monitoring in patients undergoing liver transplantation. Neurocrit Care 2012; 17:77-84. [PMID: 22644887 DOI: 10.1007/s12028-012-9721-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical monitoring of cerebral blood flow (CBF) autoregulation in patients undergoing liver transplantation may provide a means for optimizing blood pressure to reduce the risk of brain injury. The purpose of this pilot project is to test the feasibility of autoregulation monitoring with transcranial Doppler (TCD) and near-infrared spectroscopy (NIRS) in patients undergoing liver transplantation and to assess changes that may occur perioperatively. METHODS We performed a prospective observational study in 9 consecutive patients undergoing orthotopic liver transplantation. Patients were monitored with TCD and NIRS. A continuous Pearson's correlation coefficient was calculated between mean arterial pressure (MAP) and CBF velocity and between MAP and NIRS data, rendering the variables mean velocity index (Mx) and cerebral oximetry index (COx), respectively. Both Mx and COx were averaged and compared during the dissection phase, anhepatic phase, first 30 min of reperfusion, and remaining reperfusion phase. Impaired autoregulation was defined as Mx ≥ 0.4. RESULTS Autoregulation was impaired in one patient during all phases of surgery, in two patients during the anhepatic phase, and in one patient during reperfusion. Impaired autoregulation was associated with a MELD score >15 (p = 0.015) and postoperative seizures or stroke (p < 0.0001). Analysis of Mx categorized in 5 mmHg bins revealed that MAP at the lower limit of autoregulation (MAP when Mx increased to ≥ 0.4) ranged between 40 and 85 mmHg. Average Mx and average COx were significantly correlated (p = 0.0029). The relationship between COx and Mx remained when only patients with bilirubin >1.2 mg/dL were evaluated (p = 0.0419). There was no correlation between COx and baseline bilirubin (p = 0.2562) but MELD score and COx were correlated (p = 0.0458). Average COx was higher for patients with a MELD score >15 (p = 0.073) and for patients with a neurologic complication than for patients without neurologic complications (p = 0.0245). CONCLUSIONS These results suggest that autoregulation is impaired in patients undergoing liver transplantation, even in the absence of acute, fulminant liver failure. Identification of patients at risk for neurologic complications after surgery may allow for prompt neuroprotective interventions, including directed pressure management.
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Pretransplant Neurological Presentation and Severe Posttransplant Brain Injury in Patients With Acute Liver Failure. Transplantation 2012; 94:768-74. [DOI: 10.1097/tp.0b013e3182620596] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Gómez Cabeza de Vaca V, Bernal Bellido C, Álamo Martínez J, Suárez Artacho G, Marín Gómez L, Serrano Díaz-Canedo J, Padillo Ruiz F, Gómez Bravo M. Liver Transplantation Due to Fulminant Hepatic Failure. Transplant Proc 2012; 44:2076-7. [DOI: 10.1016/j.transproceed.2012.07.069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Kamat P, Kunde S, Vos M, Vats A, Gupta N, Heffron T, Romero R, Fortenberry JD. Invasive intracranial pressure monitoring is a useful adjunct in the management of severe hepatic encephalopathy associated with pediatric acute liver failure. Pediatr Crit Care Med 2012; 13:e33-8. [PMID: 21263362 PMCID: PMC3108011 DOI: 10.1097/pcc.0b013e31820ac08f] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Pediatric acute liver failure is often accompanied by hepatic encephalopathy, cerebral edema, and raised intracranial pressure. Elevated intracranial pressure can be managed more effectively with intracranial monitoring, but acute-liver-failure-associated coagulopathy is often considered a contraindication for invasive monitoring due to risk for intracranial bleeding. We reviewed our experience with use of early intracranial pressure monitoring in acute liver failure in children listed for liver transplantation. DESIGN AND PATIENTS Retrospective review of all intubated pediatric acute liver failure patients with grade III and grade IV encephalopathy requiring intracranial pressure monitoring and evaluated for potential liver transplant who were identified from an institutional liver transplant patient database from 1999 to 2009. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 14 patients were identified who met the inclusion criteria. Their ages ranged from 7 months to 20 yrs. Diagnoses of acute liver failure were infectious (three), drug-induced (seven), autoimmune hepatitis (two), and indeterminate (two). Grade III and IV encephalopathy was seen in ten (71%) and four (29%) patients, respectively. Computed tomography scans before intracranial pressure monitor placement showed cerebral edema in five (35.7%) patients. Before intracranial pressure monitor placement, fresh frozen plasma, vitamin K, and activated recombinant factor VIIa were given to all 14 patients, with significant improvement in coagulopathy (p < .04). The initial intracranial pressure ranged from 5 to 50 cm H2O; the intracranial pressure was significantly higher in patients with cerebral edema by computed tomography (p < .05). Eleven of 14 (78%) patients received hypertonic saline, and three (22%) received mannitol for elevated intracranial pressure. Eight of 14 (56%) monitored patients were managed to liver transplant, with 100% surviving neurologically intact. Four of 14 (28%) patients had spontaneous recovery without liver transplant. Two of 14 (14%) patients died due to multiple organ failure before transplant. One patient had a small 9-mm intracranial hemorrhage but survived after receiving a liver transplant. No patient developed intracranial infection. CONCLUSIONS In our series of patients, intracranial pressure monitoring had a low complication rate and was associated with a high survival rate despite severe hepatic encephalopathy and cerebral edema in the setting of pediatric acute liver failure. In our experience, monitoring of intracranial pressure allowed interventions to treat increased intracranial pressure and provided additional information regarding central nervous system injury before liver transplant. Further study is warranted to confirm if monitoring allows more directed intracranial pressure therapy and improves survival in pediatric acute liver failure.
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Affiliation(s)
- Pradip Kamat
- Division of Critical Care, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA.
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Kantola T, Ilmakunnas M, Koivusalo AM, Isoniemi H. Bridging Therapies and Liver Transplantation in Acute Liver Failure; 10 Years of MARS Experience from Finland. Scand J Surg 2011; 100:8-13. [PMID: 21482500 DOI: 10.1177/145749691110000103] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Acute liver failure is a life-threatening condition in the absence of liver transplantation option. The aetiology of liver failure is the most important factor determining the probability of native liver recovery and prognosis of the patient. Extracorporeal liver assist devices like MARS (Molecular Adsorbent Recirculating System) may buy time for native liver recovery or serve as bridging therapy to liver transplantation, with reduced risk of cerebral complications. MARS treatment may alleviate hepatic encephalopathy even in patients with a completely necrotic liver. Taking this into account, better prognostic markers than hepatic encephalopathy should be used to assess the need for liver transplantation in acute liver failure.
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Affiliation(s)
- T. Kantola
- Department of Anaesthesiology and Intensive Care Medicine
| | - M. Ilmakunnas
- Department of Anaesthesiology and Intensive Care Medicine
| | | | - H. Isoniemi
- Transplantation and Liver Surgery Clinic Helsinki University Hospital, Helsinki, Finland
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