Acute liver failure (ALF) in a specialist intensive care unit: a 7 year experience

Abstract

Background: Whole body hyperthermia induced by radiative systems has been used in therapy of malignant diseases for more than ten years. Von Ardenne and co-workers have developed the 'systemiche Krebs-Mehrschritt-Therapic' (sKMT), a combined regime including whole body hyperthermia of 42°C, induced hyperglycaemia and relative hyperoxaemia with additional application of chemotherapy. This concept has been employed in a phase I/II clinical study for patients with metastatic colorectal carcinoma at the Virchow-Klinikum since January 1997. Methods: The sKMT concept was performed eleven times under intravenous general anaesthesia, avoiding volatile anaesthetics. Core temperatures of up to 42°C were reached stepwise by warming with infrared-A-radiation (IRATHERM 2000®). During the whole procedure blood glucose levels of 380-450 mg/dl were maintained as well as PaO 2 levels above 200 mmHg. Extensive invasive monitoring was performed in all patients including measurements with the REF-Ox-Pulmonary artery catheter with continuous measuring of mixed venous saturation (Baxter Explorer®) and invasive monitoring of arterial blood pressure. Data for calculation of hemodynamic and gas exchange parameters were collected four times, at temperatures of 37°C, 40°C, 41.8-42°C and 39°C, during measurements FiO 2 was 1.0 at all times. Fluids were given in order to keep central-venous and Wedge pressure within normal range during the whole procedure. Statistics were performed using the Wilcoxon Test. Results: Statistically significant differences were found between heart rate, cardiac index and systemic vascular resistance comparing data at 37°C and 42°C. Heart rate and cardiac index increased to a maximum at 42°C (P < 0.0001) whereas systemic vascular resistance had its minimum at 42°C (P < 0.0001). Mean arterial pressure dropped with increasing temperature, differences were not significant. Calculation of stroke volume index and ventricular volumes showed only a slight decrease in endsystolic volumes with increasing temperature, the resulting differences in right ventricular ejection fraction were marginally significant (P = 0.038) comparing 42°C to baseline. Right ventricular stroke work index as well as mean pulmonary arterial pressure increased at 42°C (P = 0.0115 and P = 0.0037), pulmonary vascular resistance only dropped little compared to systemic vascular resistance, left ventricular stroke work index even dropped with increasing temperature, though showing no significant difference. Values for mixed venous oxygen saturation did not vary during therapy, pulmonary right-left shunt showed a temperature associated increase (P = 0.0323) to a maximum at 42°C. Conclusion: Under the procedure of sKMT cardiac function in patients, who do not have any pre-existing cardiac impairment, can be maintained almost unchanged, ie with normal right and left ventricular pressure, despite an increase in right ventricular stroke work Acknowledegment: Supported by Deutsche Krebshilfe.

Aetiology and outcome of acute hepatic failure in Greece: experience of two academic hospital centres

“…The findings of this study emphasize the need for better public health policy and medical consultation in the general population. Recent studies suggest that HBV accounts for FHF in 27.6% of the cases in India, 20% in the USA (14) and 2% in the UK (15). A very encouraging issue is the finding that the rate of HBV‐related FHF in Greece has decreased from 74% in the early 1980s (9) to 52.5% over the last 6 years, despite the immigrant wave in Greece from countries with a high HBV infection rate.…”

Delta model for end-stage liver disease and delta clinical prognostic indicator as predictors of mortality in patients with viral acute liver failure

“…The etiology of ALF shows marked worldwide variation; viral causes predominate in the developing world, whereas drug-induced hepatotoxicity and seronegative hepatitis predominate the western world. [ 10 11 12 13 14 15 ] The only definitive treatment option is liver transplant (orthotopic or living donor or auxiliary) along with supportive care. Mortality in centers with liver transplant facilities ranges between 21% and 41%.…”

Changing Patterns of Causation and the Use of Transplantation in the United Kingdom

“…1 Although the only therapy inate, whereas drug-induced hepatotoxicity and "seronegative" hepatitis predominate in much of the western world (Table 1). 2,3,[6][7][8][9] The importance of these differences in etiology lies in the fact that the frequency of complications and overall prognosis vary greatly with the underlying cause. 2,3 Despite the frequent occurrence of cerebral edema and renal failure in so-called hyperacute ALF (exemplified by that resulting from acetaminophen and hepatitis A), survival without transplantation is relatively good.…”

“…[11][12][13] In the United Kingdom, most ALF cases result from acetaminophen-induced hepatotoxicity. 7 Acute liver failure in this setting is a short, intense illness, with patients progressing from isolated hepatic failure to the involvement of multiple extrahepatic organ systems failure with encephalopathy, renal failure, and cardiovascular collapse in a matter of hours. 13,14 Fortunately the "superurgent" category within the U.K. transplant priority list allows ABO matched grafts to be available for most of these patients within 24 to 72 hours, and much current research activity is focused on aspects of the supportive care of unstable ALF patients as well as on finding better methods for the early detection of those patients who will require transplantation.…”

“…Two large ALF case series have been reported from the Institute of Liver Studies at King's College Hospital, London, covering the period from 1973 to 1997 (see Table 1). 7,38,39 These show a major increase in the proportion of cases resulting from acetaminophen-induced hepatotoxicity and a corresponding reduction in those with a viral or presumed infective cause. More than 75% of a series of nearly 1000 cases admitted between 1991 and 1997 resulted from drug-induced hepatotoxicity, and, of these, more than 90% resulted from acetaminophen ingestion.…”