Multidisciplinary management approach to fulminant hepatic encephalopathy in the neurocritical care unit: A single-center experience
Rehman M, Mehta C, Ramadan R, Howell B, Elkambergy H, and Mayer S. Multidisciplinary management approach to fulminant hepatic encephalopathy in the neurocritical care unit: A single-center experience. Neurology 2018; 90(15 Suppl 1):P4.325.
Objective: Measure and change mortality/morbidity in patients with Fulminant Hepatic encephalopathy (FHE) using aggressive multimodality monitoring and multidisciplinary approach. Background: Fulminant hepatic encephalopathy (FHE) with diffuse cerebral edema has dismal prognosis if transplantation is not performed. Novel therapeutic interventions may change this outcome. Design/Methods: We reviewed all cases with FHE admitted to our hospital since 2008. In 2010, we developed a multidisciplinary management protocol, mandating transfer of patients entering grade 3 from other ICUs to the Neurosciences-ICU (NICU) for intracranial pressure (ICP) management. Multiple interventions were utilized including coagulopathy reversal with Factor VII and prothrombin complex concentrate (PCC, Kcentra), ICP device placement, osmotherapy, aggressive ammonia lowering regimen with lactulose and rifaximin, early renal replacement therapy, mild hypothermia for refractory ICP, in conjunction with liver transplantation candidacy investigation. Results: Twenty-four patients (19 women, mean age of all patients 40 years) were admitted; seven were managed in the MICU/SICU and 17 in the NICU. The etiology of FHE was acetaminophen toxicity in 72% of patients. The Model for End-Stage Liver Disease (MELD) admission scores and liver enzymes between the MICU/SICU and the NICU were not different (Mann- Whitney test). Although the NICU admission ammonia level was higher than the MICU/SICU (168.75 vs 99.50, p = 0.00), the lowest achieved ammonia was lower in the NICU (41.31 vs 7978.13, p = 0.022, Mann-Whitney). Patients received ICP monitoring (all in the NICU plus 2 in the SICU) and the highest ICP recorded was 120 mm Hg. The pre- and post- coagulation reversal INR were 3.37 and 1.3, p=0.031, Wilcoxon test). Seven patients in the NICU received hypothermic treatment. Mortality in the MICU/SICU was 85.7% (6/7) and in the NICU 41.1% (7/17), p = 0.13 (chi square test). Conclusions: A multidisciplinary approach centered around anti-cerebral edema protocol-driven management based on novel interventions may improve the outcome of patients with FHE.
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