Editorial

Successful management & Early Recovery of a patient with Acute Liver Failure with timely Liver Transplant, aided by Peri-Operative

monitoring of Optic Nerve Sheath Diameter and Early initiation of Renal replacement therapy – A Case Report

Anupam Raj¹, Vijay Shankar¹, Meera Kharbhanda¹, Neerav Goyal²

Keywords: Acute Liver Failure, Cerebral Edema, Pregnancy, Hepatitis E, Liver Transplant, Continuous Renal Replacement Therapy

A 32-year-old female patient was admitted in our hospital with a diagnosis of Hepatitis E induced acute liver failure. She was immediately intubated and mechanically ventilated due to a high grade of hepatic encephalopathy. ONSD measured on admission was suggestive of raised ICP. She was initiated on CRRT along with other anti-edema measures. She underwent LDLT on the third day of admission. ONSD was monitored at regular intervals to identify cerebral edema and CRRT was continued intra operatively with the aim of preventing cerebral edema. We were able to extubate the patient within 18 hours of the surgery. The patient had a fastpost-operative recovery and we were able to discharge her on the 12th post-operative day.

Case Report

Abstract

Journal of Anaesthesia and Critical Care Case Reports 2019 Jan-April;5(1):18-20

2Dept Of Liver Transplantation , I ndraprastha Apollo Hospital New Delhi

Address of Correspondence

1Department of Anaesthesia, Indraprastha Apollo Hospital New Delhi

Department of Anaesthesia, Indraprastha Apollo Hospital New Delhi Dr. Anupam Raj,

Email: anupamraj21@gmail.com

© 2019 by Journal of Anaesthesia and Critical Care Case Reports| Available on www.jaccr.com | This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial

use, distribution, and reproduction in any medium, provided the original work is properly cited.

Journal of Anaesthesia and Critical Care Case Reports Volume 5 Issue 1 Jan-April 2019 Page 18-2018 | | || |

Dr. Anupam Raj Dr. Vijay Shankar

A 31-year-old female, 8 months and 2 weeks pregnant was admitted in a local hospital in v i e w o f j a u n d i c e f o r a d a y. I n i t i a l investigations over there showed deranged LFTs with a viable foetus. She underwent LSCS under GA. However, following the LSCS her sensorium worsened along with 2 episodes of lower gastrointestinal bleed. She was referred to the liver transplant unit of our hospital for further management with a diagnosis of HEV induced Acute Liver failure.

Hepatitis E is the most common cause of hepatitis in developing countries. It can lead to acute liver failure especially in pregnant females, with the severity of infection and mortality rate increases with the gestational age. Cerebral edema leading to intracranial hypertension (ICH) is a major cause of mortality in patients with acute liver failure. Studies have found out that only < 25 % of cases of raised intracranial pressures could be diagnosed by clinical examination alone. Even though many guidelines recommend invasive intracranial pressure monitoring (ICP) for Acute Liver Failure (ALF), the use of these modalities have shown to cause hemorrhagic complications because of the coagulopathy associated with ALF. However, monitoring of ICP may be beneficial in i d e n t i f y i n g I C H a n d g u i d i n g t h e administration of targeted therapy. The measurement of optic nerve sheath diameter (ONSD) is a non-invasive and reliable

technique with proven efficacy in detecting elevations of ICH in neurosurgical patients. Most of the studies have recommended a cut off value of > 0.48 cm as an indicator of ICP > 20 mm Hg. ONSD measurement is non-invasive, rapid, easy & requires less expertise which could be crucial in early identification of intracranial hypertension during the pre-o p e r a t i v e a s w e l l a s i n t r a o p e r a t i v e managem ent o f a pat i ent w i t h A L F undergoing liver transplantation.

On admission to the transplant ICU, she was

Case Report

We present a case of a lady who was admitted in our hospital with ALF. Diagnosis of raised intracranial pressure was established at the time of admission by measurement of ONSD and CRRT was initiated. Living Related Liver Transplantation was done on the 2nd day of admission and was discharged on the 12th postoperative day

Hyperammonemia is an important cause of brain edema in patients with acute liver failure. Ammonia levels of > 150-200µmol/l have been co-related to increased intracranial pressure and brainstem herniation. In addition to the conventional anti ammonia measures, renal replacement therapy (RRT), can also be used to lower blood ammonia levels. The Current standard is to use CRRT as a modality to reduce ammonia levels in A L F pat i e n t s ow i ng to i t s s u p e r i o r haemodynamic stability.

Introduction

Dr. Meera Kharbhanda Dr. Neerav Goyal

Raj A et al www.jaccr.com

Journal of Anaesthesia and Critical Care Case Reports Volume 5 Issue 1 Jan-April 2019 Page 18-2019 | | || |

Discussion

A mong the numerous per ioperat ive concerns, one of paramount importance was the optimal monitoring and management of surges in intracranial pressure during the intraoperative period. A CT brain was performed prior to shifting the patient to the theatre which showed features of mild cerebral edema with no signs of herniation. Anaesthesia was induced using intravenous fentanyl and inhalation of sevoflurane t h r o u g h t h e a l r e a d y p r e - e x i s t i n g endotrachealtube and was maintained by c o n t i n u o u s i n f u s i o n o f p ro p o f o l at 6mg/kg/hour and atracur ium at 0.3 mg/kg/hour. Due to the anticipated fluid and electrolyte shifts during the operation which could exacerbate her cerebral edema it was decided to monitor her ONSD at 2nd intervals during the surgical procedure. C R R T w a s c o n t i n u e d d u r i n g t h e

intraoperative phase also with the aim of preventing cerebral edema and acidosis. The ONSD in both the eyes remained within 0.47 mm throughout the procedure. The surgery lasted around 12 hours and was largely uneventful.

f o u n d t o b e o n g r a d e 3 h e p a t i c encephalopathy, tachycardic, tachypnoeic, normotensive and normothermic. Pupils were reacting, however, the ONSD was found to be 0.49 cm in both the eyes. A decision was made to selectively intubate and ventilate the patient and initiate CRRT with the aim of lowering serum ammonia levels. The investigations on admission are given in table1.

In the ICU acidosis was corrected overnight, inotropic support weaned off, CRRT was discontinued since ONSD was within the normal range. She was extubated after 18 hours. Graft function improved satisfactorily, immunosuppression and antibiotics were continued as per protocol. She was shifted out of the ICU on post-operative day 5 and discharged by the 11thpostoperative day. Her postoperative investigations are given in table 2.

After intubation, venous & arterial access was obtained under ultrasound guidance for haemodynamic monitoring. A 11 fr dialysis catheter was secured in the right femoral vein under ultrasound guidance. CRRT was initiated immediately with ultrafiltrate at 0 ml per hour since urine output was more than 1 ml/kg/hour. Other antioedema measures l i k e h e a d u p p o s i t i o n , m o d e r a t e hyperventilation, mannitol, and hypertonic saline to maintain serum sodium between 150-155 mmol/l were initiated. Special care was taken to avoid hyperthermia and maintain the temperature at around 35 degrees. Pupillary reaction and ONSD were measured hourly and within 3 hours of initiation of CRRT, it was noted that the ONSD was < 0.47 mm in both the eyes. All

the ONSD measurements were done by a single operator. She met the king’s college cr iter ia for l iver transplantation. An emergency meeting by a multi-disciplinary team was called for and it was decided to go ahead with emergency living related liver transplantation after the family counseling and donor work-up was done.

Various forms of RRT have been used to treat inborn errors of metabolism in neonates and children. A recent review article on the treatment of liver failure proposed that ammonia clearance could be achieved by u s i n g c o n v e n t i o n a l c o n t i n u o u s hemofiltration, with higher rates of clearance

Prevention, early identi f ication, and treatment of cerebral edema are of paramount importance in improving outcomes in acute liver failure. Traditional monitors of ICP carry a high risk of bleeding and infection. Raised ICP is transmitted to the optic sheath through the subarachnoid space. The mechanism is like the development of papilledema. However, unlike papilledema, the optic nerve sheath distention occurs within a matter of seconds which makes ONSD a valuable tool to diagnose acute elevations in ICP [5,10,11]. The largest study c o - r e l a t i n g O N S D r e a d i n g s w i t h simultaneous ICP measurements were performed by Rajajee et al[5] in 65 patients and demonstrated that an ONSD of > 0.48 cm corresponded to an ICP> 20 mm Hg. In our patient an elevated ONSD on admission prompted us to initiateanti-edema measures in the form of CRRT, mannitol, hy p er to n i c s a l i n e, e tc i m m ed i ate l y. I n t r a o p e r a t i v e I C H h a s a l s o b e e n demonstrated during OLT especially in the anhepatic phase and reperfusion even in patients who did not exhibit raised ICP pre-operatively[12]. Hence, we continued monitoring ONSD at hourly intervals during the intraoperative period as well and noticed a spike in ONSD measurements during the anhepatic phase w hich sett led post-reperfusion.

HAEMATOLOGY LFT RFT

Haemoglobin/PCV 12.3/38.9Serum Bilirubin/Direct

bilirubin9.9/6.6 Urea/creat 10/0.4

TLC 16,780 SGOT/SGPT 157/436 Uric Acid 1.2

Platelet Count 327000 SAP/GGTP 313/22 Na/K 144/3.6

PT/INR 75.7/7.1 Albumin 1.8

aPTT 77.2 Globulin 2.1

Serum Ammonia 164

Table 1 : Investigations on admission

POD1 POD3 POD6 POD10 DISCHARGE

HB 8.9 7.4 9.1 10.1 10.4

TLC 7070 10950 11780 13540 13820

PLATELETS 148000 61000 123000 332000 397000

TOTAL BILIRUBIN 10.7 1.3 1.4 1.4 1.1

DIRECT BILIRUBIN 6.9 0.9 0.9 0.9 0.8

AST 92 58 66 98 102

ALT 287 127 115 211 242

SAP 257 62 129 359 482

ALBUMIN 2.5 2.5 3.3 3.7 4.1

PT/INR 50.3 16.7 11.2

INR 4.7 1.6 0.9

UREA 10 69 19 49 46

CREATININE 0.4 0.4 0.6 0.4 0.4

SODIUM 146 144 140 141 138

POTASSIUM 3.9 4.1 5.3 4.3 4

Table 2: Post Operative Investigations

www.jaccr.comRaj A et al

Raj A, Shankar V, Kharbhanda M, Goyal N. Successful management & Early Recovery of a patient with Acute Liver Failure with timely Liver Transplant, aided by Peri-Operative monitoring of Optic Nerve Sheath Diameter and Early initiation of Renal replacement therapy – A Case Report. Journal of Anaesthesia and Critical Care Case Reports Jan-April 2019;5(1):18-20.

How to Cite this Article

Conflict of Interest: Nil Source of Support: None

Journal of Anaesthesia and Critical Care Case Reports Volume 5 Issue 1 Jan-April 2019 Page 18-2020 | | || |

c o r r e l a t i n g w i t h h i g h e r r a t e s o f hemofiltration[14]. The authors cited a study by Slack et al[15]. who conducted one of the first studies evaluating Continuous venovenous hemodiafiltration [CVVHD] in adult pat ients w ith l iver fai lure and hyperammonemia. In this prospective cohort study, the investigators examined that there was a meaningful decline in arterial ammonia concentrations with ultrafiltration. The low molecular weight and low plasma protein binding properties of ammonia make it more amenable to dialysis. Even though there isn’t any consensus as to when to initiate CRRT in ALF, we believe it should be implemented

early in the progression to hyperammonemia and before the development of AKI, so that the concentration of ammonia will not rise to clinically signif icant levels. Surges in intracranial pressure could happen during the intraoperative phase also owing to the massive fluid and electrolyte shifts during liver transplantation. So, we decided to continue CRRT during the intraoperative phase too.

ConclusionWe were able to extubate the patient within 18 hours and discharge the patient on the 11 th post- operative day. In our scenario use of

ONSD pre-operat ively &amp; intra-operatively to identify raised ICP followed by rapid init iat ion of CRRT w hich was continued throughout the intra-operative period helped us in treating cerebral edema s e c o n d a r y t o h y p e r a m m o n e m i a perioperatively. We would like to point out that ONSD which has an easier learning curve might be a usual adjunct to non- invasively track cerebral edema in patients with acute liver failure..

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The case for quadruple-H therapy. Anaesth Intensive Care 42: 78–88, 2014

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