Multidisciplinary management approach to fulminant hepatic encephalopathy in the neurocritical care unit: A single-center experience
Rehman MF. Multidisciplinary management approach to fulminant hepatic encephalopathy in the neurocritical care unit: A single-center experience. Neurocritical Care 2017; 27(2):S221.
Introduction Introduction: Fulminant hepatic encephalopathy (FHE) with diffuse cerebral edema has dismal prognosis if transplantation is not performed. Novel therapeutic interventions may change this outcome. Methods 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 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 78.13, 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 preand 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 Conclusion: A multidisciplinary approach centered around Anti-cerebral edema protocol-driven management based on novel interventions may improve the outcome of patients with FHE.