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Results of a protocol for the management of patients with fulminant liver failure*

Raschke, Robert A. MD, MS; Curry, Steven C. MD; Rempe, Silke MD; Gerkin, Richard MD; Little, Ester MD; Manch, Richard MD; Wong, Mark MD; Ramos, Alberto MD; Leibowitz, Alan I. MD

doi: 10.1097/CCM.0b013e31818029a3
Continuing Medical Education Article

Objective: To assess the safety and efficacy of a protocol to support management of intracerebral pressure in patients with fulminant liver failure (FLF).

Design and Setting: A prospective series was conducted between May 2004 and September 2006 at Banner Good Samaritan Medical Center, a 650-bed teaching hospital in Phoenix, Arizona.

Patients: We recruited consecutive patients with FLF and stage 3 or 4 encephalopathy.

Interventions: We placed an intracranial pressure monitor in each patient and employed a protocol to support decisions regarding hemostatic management and prevention and treatment of intracranial hypertension (IHTN). Treatment modalities included hypothermia, hypocarbia, intravenous pentobarbital, intravenous mannitol and vasopressor titration for maintenance of cerebral perfusion pressure. The main outcome measure was survival in transplant candidates.

Measurements and Main Results: Twenty-two patients entered the study and 21 (95%) had at least one episode of IHTN. Eighty-two discrete episodes of IHTN occurred, and 78 of these (95%) resolved with treatment. Overall survival was 55%. Eleven of 18 (61%) of transplant candidates survived with good neurologic outcome. No patient died from isolated cerebral edema. Three patients had intracranial hemorrhages related to the intracranial pressure monitor.

Conclusions: Protocol-driven management of intracranial pressure in FLF can result in good clinical outcomes in most transplant candidates, even if IHTN occurs.

LEARNING OBJECTIVES On completion of this article, the reader should be able to:

  1. Explain the most common cause of death in fulminant liver failure.
  2. Describe the protocol for management of patients with fulminant liver failure.
  3. Use this information in a clinical setting.

Dr. Raschke has disclosed that he was a consultant/advisor for Cardinal Health and attended and spoke at several paid meetings and conferences in regards to intravenous heparin. The remaining authors have not disclosed any potential conflicts of interest. The authors have disclosed that the U.S. Food and Drug Administration has not approved pentobarbital for the treatment of intracranial hypertension discussed in this article. Please consult the product's labeling information for approved indications and usage.

All faculty and staff in a position to control the content of this CME activity have disclosed that they have no financial relationship with, or financial interests in, any commercial companies pertaining to this educational activity.

Lippincott CME Institute, Inc., has identified and resolved all faculty conflicts of interest regarding this educational activity.

Visit the Critical Care Medicine Web Site ( for information on obtaining continuing medical education credit.

Medical Director of Critical Care (RAR), Director of Department of Medical Toxicology (SCC), Pulmonary Critical Care Fellow, Department of Medicine, Section of Critical Care Medicine (SR), Medical Director, Graduate Medical Education, Research (RG), Chairman of Medicine (AIL), Banner Good Samaritan Medical Center, Phoenix, AZ; Associate Director (EL), Director (RM), Associate Medical Director (MW), Hepatology Consultant (AR), Liver Disease Center, Banner Good Samaritan Medical Center, Phoenix, AZ; Professor of Clinical Medicine (RAR, SCC, AIL), University or Arizona School of Medicine, Phoenix, AZ; Associate Professor of Clinical Medicine (RG), University of Arizona, Tucson, AZ; and Clinical Assistant Professor of Medicine (EL), University of Arizona, Phoenix, AZ.

There was no research support funding for this study.

For information regarding this article, E-mail:

The authors have not disclosed any potential conflicts of interest.

© 2008 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins