Acute fulminant hepatic failure

Fulminant hepatic failure is the rapid onset of life-threatening hepatic decompensation in patients who have no previous history of liver disease. This condition has a multifactorial etiology, including viral hepatitis and drug toxicity. At this time there is no specific therapy for FHF. However, early diagnosis and treatment of the complications--in particular, cerebral edema--may prolong survival and prevent irreversible neurologic complications. Once the diagnosis has been made, patients with FHF should promptly be transferred to a specialized liver care unit where liver transplantation is available. Liver transplantation is now the treatment of choice for patients with clinical characteristics suggesting a poor chance of survival.     

Intensive care unit management of patients with stroke

Opinion statement Patients admitted with the diagnosis of “stroke” have a variety of different disorders that require specific treatment approaches in the critical care unit. Early thrombolysis for ischemic stroke and improvements in surgical and neurointerventional techniques for the treatment of aneurysms and arteriovenous malformations in patients with subarachnoid hemorrhage have been milestones in the past decade, but the evolvement of general management principles in critical care and the dedication of neurointensivists are equally important for improved outcomes. Strategies, which have been developed in other areas of intensive care medicine (eg, in patients with septic shock, acute respiratory distress syndrome, or trauma), need to be adopted and modified for the stroke patient. Prevention of iatrogenic complications and nosocomial infections is of utmost importance and requires sufficient numbers of trained personnel and high-quality equipment. Although the focus of attention in stroke patients is “brain resuscitation,” comorbidities often limit the diagnostic and therapeutic options, and overall cardiopulmonary and metabolic functions need to be optimized in order to prevent secondary injury and allow the brain to recover. As part of a holistic approach to the rehabilitation process, psychologic and spiritual support for the patient must start early on in the intensive care unit, and family members should be involved in the patient’s care and provided with special support as well.     

Intensive care unit management of interventional neuroradiology patients

The management of interventional neurologic patients in the intensive care unit is based on their underlying disease for the most part. Patients with ischemic stroke are largely managed like patients with ischemic stroke who have not undergone interventional procedures, and the same is true for those with an aneurysmal subarachnoid hemorrhage or intracerebral hemorrhage secondary to an arteriovenous malformation, for example.Having said this, there are some special considerations that require special mention when it comes to managing patients after catheter-based procedures.     

Halothane induced fulminant hepatic failure

A rare case of halothane-induced fulminant hepatic failure is reported in a 22 years old male, who developed fever, jaundice, coma and deranged coagulation profile, 2 days after undergoing laparotomy under halothane anaesthesia. Despite all supportive care, he died of fulminant hepatic failure, 6 days after surgery. Postmortem liver biopsy revealed massive predominantly centrilobular hepatic necrosis.     

Management options in fulminant hepatic failure

The diagnosis of FHF carries with it a high mortality rate. Though the early results of OLT for FHF are encouraging, some have called for caution as these results are in a select population and may be similar to the optimistic early reports of now-discredited therapies. However, OLT differs fundamentally from all other interventions and, as such, it is ethically unjustified to withhold potentially life-saving therapy from patients with a predicted mortality in excess of 60%. Therefore, patients with FHF should be transferred at an early stage to an experienced liver unit where the option of liver transplantation can be considered.     

Liver transplant for fulminant hepatic failure

Fulminant hepatic failure is a challenging indication for liver transplantation because of associated multiple organ failure, profound neurologic abnormalities and coagulopathy. Sixteen patients have undergone emergent orthotopic liver transplantation for this indication at the University of Michigan, Ann Arbor, Michigan. Despite the associated problems, patient survival (68.2% at 2 years), intra-operative blood product utilization and duration of surgery were comparable to patients receiving liver transplants for other indications. All patients experienced complete recovery from preoperative neurologic abnormalities. Recurrent viral hepatitis did occur but did not result in allograft loss. For selected patients, orthotopic liver transplantation is excellent therapy for patients presenting with fulminant hepatic failure.     

Orthotopic liver transplantation for fulminant hepatic failure

This paper presents the results of liver transplantation for fulminant hepatic failure in 31 patients qualified as UNOS-1 class (extra-urgent indication for transplantation), operated from January 1989 to April 2005. Twenty-one patients (61.8%) survived the 3-month postoperative period. Three-year survival rate with good liver graft function was 52.9% (18 patients). Before the transplantation, eight patients (23.5%) underwent hepatic dialysis using Fractionated Plasma Separation and Adsorption (FPSA) with the use of a Prometheus 4008H System. Liver transplantation remains the only life-saving procedure for the treatment of fulminant liver failure, regardless of its cause.     

Transcranial Doppler sonography in fulminant hepatic failure

The clinical course of patients with fulminant hepatic failure (FHF) is often worsened by the presence of cerebral edema and endocranial hypertension. In spite of the multiple studies using Transcranial Doppler Sonography (TCDS), few have shown the cerebral blood flow (CBF) pattern among patients with encephalopathy resulting from FHF. OBJECTIVE: Our objective was to characterize the CBF pattern in these patients through the use of TCDS to provide therapeutic strategies. METHOD: The TCDS pattern was assessed in five patients diagnosed with FHF and compared with a control group who displayed critical neurologic conditions not associated with FHF. Pulsatile index, systolic, diastolic, and mean velocity of the middle cerebral artery were measured. RESULTS: The mean age of patients with FHF was 45.4 years. One hundred percent were women, with viral hepatitis as the predominant etiology. A cerebral hypoperfusion pattern was found in 80% of the FHF group and 40% of the control group. In the former group there was no evidence of hyperemia, as there was among 20% of the control group. The mean values of velocity and pulsatile index were 36.6 cm/sec and 2.4, respectively, in the FHF group and 47.8 cm/s and 1.8 in the control group (P=0.268, P=0.402). CONCLUSIONS: FHF patients show a predominance of cerebral hypoperfusion pattern with mean velocities lower than normal values and an increased pulsatile index. We recommend that clinicians take appropriate measures to improve cerebral perfusion and avoid hypoxia. Hyperventilation as a first level measure is contraindicated.     

Intensive care unit acquired weakness

Intensive care unit acquired weakness (ICUAW) is an acute clinical weakness that occurs in approximately 50% of ICU patients and is directly attributable to their critical care stay where other causes of weakness have been excluded. The condition is characterized by diffuse limb and respiratory muscle weakness with a relative sparing of the cranial/facial muscles and the autonomic nervous system. Patients with ICUAW are classified into three conditions: critical illness polyneuropathy (CIP), critical illness myopathy (CIM) or critical illness neuromyopathy (CINM) based on clinical criteria and further defined by electrophysiological studies and muscle biopsies. ICUAW is often a manifestation of immobility or a systemic inflammatory response syndrome, especially in long-term ventilated patients who have had systemic sepsis/multiorgan failure or exposure to high-dose corticosteroids, neuromuscular blockers or hyperglycaemia. It is associated with prolonged weaning from mechanical ventilation, increased mortality/length of ICU stay and long-term disability.     

Intensive care unit acquired weakness

Intensive care unit acquired weakness (ICUAW) is an acute clinical weakness that occurs in approximately 50% of ICU patients and is directly attributable to their critical care stay where other causes of weakness have been excluded. The condition is characterized by diffuse limb and respiratory muscle weakness with a relative sparing of the cranial/facial muscles and the autonomic nervous system. Patients with ICUAW are classified into three conditions: critical illness polyneuropathy (CIP), critical illness myopathy (CIM) or critical illness neuromyopathy (CINM) based on clinical criteria and further defined by electrophysiological studies and muscle biopsies. ICUAW is often a manifestation of immobility or a systemic inflammatory response syndrome especially in long-term ventilated patients who have had systemic sepsis/multiorgan failure or exposure to high-dose corticosteroids, neuromuscular blockers or hyperglycaemia. It is associated with prolonged weaning from mechanical ventilation, increased mortality/length of ICU stay and long term disability.