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Cerebral hemodynamic and metabolic profiles in fulminant hepatic failure: Relationship to outcome
Author(s) -
Aggarwal Shushma,
Obrist Walter,
Yonas Howard,
Kramer David,
Kang Yoogoo,
Scott Victor,
Planinsic Raymond
Publication year - 2005
Publication title -
liver transplantation
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.814
H-Index - 150
eISSN - 1527-6473
pISSN - 1527-6465
DOI - 10.1002/lt.20479
Subject(s) - medicine , cerebral blood flow , liver transplantation , fulminant hepatic failure , hemodynamics , intracranial pressure , fulminant , ischemia , pathophysiology , cardiology , mean arterial pressure , middle cerebral artery , transplantation , anesthesia , blood pressure , heart rate
The purpose of this retrospective study was to examine the potential role of cerebral hemodynamic and metabolic factors in the outcome of patients with fulminant hepatic failure (FHF). Based on the literature, a hypothetical model was proposed in which physiologic changes progress sequentially in five phases, as defined by intracranial pressure (ICP) and cerebral blood flow (CBF) measurements. Seventy‐six cerebral physiologic profiles were obtained in 26 patients (2 to 5 studies each) within 6 days of FHF diagnosis. ICP was continuously measured by an extradural fiber optic monitor. Global CBF estimates were obtained by xenon clearance techniques. Jugular venous and peripheral artery catheters permitted calculation of cerebral arteriovenous oxygen differences (AVDO 2 ), from which cerebral metabolic rate for oxygen (CMRO 2 ) was derived. A depressed CMRO 2 was found in all patients. There was no evidence of cerebral ischemia as indicated by elevated AVDO 2 s. Instead, over 65% of the patients revealed cerebral hyperemia. Eight of the 26 patients underwent orthotopic liver transplantation—all recovered neurologically, including 6 with elevated ICPs. Of the 18 patients receiving medical treatment only, all 7 with increased ICP died in contrast to 9 survivors whose ICP remained normal ( P < 0.004). Hyperemia, per se, was not related to outcome, although it occurred more frequently at the time of ICP elevations. Six patients were studied during brain death. All 6 revealed malignant intracranial hypertension, preceded by hyperemia. In conclusion, the above findings are consistent with the hypothetical model proposed. Prospective longitudinal studies are recommended to determine the precise evolution of the pathophysiologic changes. (Liver Transpl 2005;11:1353–1360.)