fulminant hepatic failure FHF

1. DR K K RAWAL
DM(GASTRO)
MILESTONE HOSPITAL
VIDYANAGAR MAIN ROAD
RAJKOT
2480843/44

2. ACUTE SEVERE VIRAL
HEPATITIS
ACUTE LIVER FAILURE
OR
FULMINANT HEPATIC FAILURE (FHF)

3. MANAGEMENT(FHF)
 GR-1 GENERAL WARD
 GR-234 ICU
STIMULATIONS – QUITE SPACE/DIM
LIGHT
TEAM - HEPATOLOGIST
INTENSIVIST
NEPHROLOGIST
TRANSPLANT SERGEON

4. INVESTIGATIONS
 CBC
 P TIME
 SGPT/SGOT/BLB/ALB
 Na/K/Mg/Cr/B SUGAR
 ABG
 EEG/CT/USG/LIVER Bx

5. INVESTIGATIONS
VIRAL SEROLOGY
 Anti-HEV IgM
 HBsAg/Anti- HBcIgM
 Anti-HAV IgM
 Anti-HCV
 HSV/CMV/EBV (IMMUNOCOMPROMISED)

6. HEPATIC
ENCEPHALOPHATHY
S/S FLAP
S/R
 AGITATION GRADE 1 +/-
70%
 DELUSION 2 +
60%
 RESTLESSNESS 3 +
50%
 FLAP 4 -
20%

7. HEPATIC ENCEPHALOPATHY
 SELECTIVE INTUBATION FOR GR-3/4
 PROPOFOL SEDATION - ICP
 HYPOGLYCEMIA PREVENTED
 PROTEIN RESTRICTION AVOIDED
(60gm/day)

8. HEPATIC ENCEPHALOPATHY
LACTULOSE
PROLONGED SURVIVAL IN GR-1/2(stravitz2007)
OVERALL SURVIVAL NOT IMPROVED
(alba2002)
ASPIRATION (INTUBATION MUST)
RISK
BOWEL DISTENSION (LT DIFFICULT)

9. HEPATIC ENCEPHALOPATHY
N0N-ABSORBABLE ANTIBIOTICS
RIFAXIMIN
 DO NOT REDUCE INFECTIONS
(rolando1996)
 DO NOT IMPROVE OUTCOME (de
jonge2003)
 RESISTANT STRAINS ?

10. HEPATIC ENCEPHALOPATHY
L-ORNITHINE-L-ASPARTATE
NOT EFFECTIVE (SK ACHARYA2009)

11. CEREBRAL EDEMA
MOST IMPORTANT CAUSE OF DEATH
PRESENT IN 80 % CASES IN GR-4

12. CEREBRAL EDEMA
CYTOTOXIC
AMMONIA
ASTROCYTES
GLUTAMINE
(OSMOTICALLY ACTIVE)
BRAIN SWELLING
ICP (INTRACRANIAL
PRESSURE)
ISCHEMIA/HERNIATION
VASOGENIC
CYTOKINES
VASODILATATION
INCREASED BLOOD
FLOW
BRAIN SWELLING

13. INCREASED ICP
 SYSTOLIC HYPERTENSION
 BRADYCARDIA
 IRREGULAR RESPIRATION
ICP MONITORING - NO BENEFIT
(bernal2007)
HIGH RISK – SUSTAINED HIGH AMMONIA
RENAL FAILURE
YOUNG AGE
HYPERACUTE TYPE

14. INCREASED ICP
TREATEMENT
 30* ELEVATION (CPP > 50 mmHg)
 ACID, FLUID, ELECTROLYTE
CORRECTION

15. INCREASED ICP
MANNITOL
 20 % IV 1gm/kg BOLUS
 REPEAT IF SERUM OSMOLARITY <
320mOsm/L
 IF VOLUME OVERLOAD –
ULTRAFILTRATION
 RESPONSE – 60%
 IMPROVED SURVIVAL (canalese1982)

16. INCREASED ICP
HYPERTONIC SALINE
 30% SALINE INFUSION – 5-20ml/hr
 Na LEVEL MAINTAINED 145-155meq/L
 ICP , NO SURVIVAL
 SMALL STUDY - 30 PATIENTS (murphy2004)
 CAN BE USED IN HIGH RISK

17. INCREASED ICP
 HYPERVENTILATION
 BARBITURATE COMA LARGE TRIALS
NEEDED
 HYPOTHERMIA
 IV INDOMETHACIN
CORTICOSTEROIDS DO NOT WORK

18. N- ACETYLECYSTEINE
 USEFUL IN GR- 1/2
 INCREASED TRANSPLANT FREE
SURVIVAL
(lee2009)

19. BLEEDING
VIT K – 10mg IV
FFP- INR >1.5
CRYOPRECIPITATE – FIBRINOGEN <100mg/dl
PLATELET TRANS. - <10000
FACTOR VII
(IF ACTIVE BLEED/INVASIVE
PROCEDURE)
NO ROLE OF PROPHYLACTIC FFP
PPI - IV GI BLEED

20. INFECTION
 PULMONARY- 47% Gm- ve E.Coli
 BLOOD- 26% Staph/Strep
 URINE- 23% Fungal
PROPHYLACTIC ANTIBIOTIC
INFECTION
- SURVIVAL NO BENEFIT(stravitz2008)

21. INFECTION
ANTIBIOTICS USED IN
 +Ve CULTURE
 RENAL FAILURE
 HYPOTENSION
 CLINICAL DETERIORATION
 SIRS –
T>38.3,HR>90,RR>20,WBC>10K/<4K
 WAITING FOR LT

22. DRUGS TO AVOID
 SEDATIVES
 NEPHROTOXIC DRUG
 IV CONTRAST AGENTS

23. ANTIVIRAL DRUGS
 HEP B
SURVIVAL (yu2010)
POST LT REINFECTION (dao2012)
 HSV
SKIN RASH/IMMUNOCOMPROMISED
ACYCLOVIR 30mg/kg/day IV

24. SEIZURES
 PROPHYLACTIC TREATMENT - NO
BENEFIT
(SK ACHARYA2004)
 PHENYTOIN USED AFTER SEIZURE
 REFRACTORY- MIDAZOLAM,
LEVETIRACETAM

25. RENAL FAILURE
30 – 70%
DOPAMINE NOT USEFUL (bellomo2000)
ATN - >10mEq/L URINE Na
PRERENAL/HRS - <10mEq/L
CVVH – CORRECTS FLUID OVERLOAD
(lai2007) K/NH3

26. LIVER TRANSPLANT
KING’S COLLEGE CRITERIA
PT >100s (INR >7)
OR ANY 3/5
1. AGE <10 or >40
2. PT >50s (INR >3.5)
3. NON--A-E HEPATITIS
4. BLB >17.4mg/dl
5. JAUNDICE TO ENCEPHALOPHATHY >7
days

27. LIVER SUPPORT SYSTEMS
ARTIFICIAL BIOARTIFICIAL
MARS (CANADA) HEPAT-
ASSIST(USA)
ALB-IMPREG.MEMBRANE PORCINE
HEPATOCYTES
HEPATOBLASTOMA CELL
LINES

28. Blood is perfused through a specific membrane
dialyzer which uses albumin as Molecular Adsorbent
that is Recyled in a Dialysis/Sorbent System (MARS) :
(1) Blood flow:
150-500 ml/min
(2) Albumin flow:
100-(250)-1000 ml/min
(3) Dialysate:
30-800 ml/min (1)
(2)
(3)

29. HepatAssist Liver Support System

30. HepatAssist Liver Support System

31. LIVER SUPPORT SYSTEMS
NO MORTALITY BENEFIT
TEMPORARY MEANS TILL LT

32. LATEST INDIAN APPROACH
SK SARIN, GB PANT HOSPITAL, N. DELHI
G-CSF MOBILISES B-MARROW STEM CELLS
PROMOTE HEPATIC REGENERETION
47 Pt, G-CSF 5mcg/kg sc/day-5 days,/3days-5wk
(ACLF) AT 60 Days PROBABILITY OF
SURVIVAL
HRS
HE
SEPSIS
(GASTROENTEROLOGY 2012)

33. ACUTE LIVER FAILURE
Summary
 Recognition is KEY!
 Rapid assessment of prognosis is of next
importance
 Management is directed towards anticipation and
prophylaxis for known complications
 Liver support systems may gap bridge till LT
 Liver transplantation is the treatment of choice