DOCSLIB.ORG

Acute Liver Failure in Adults: an Evidence- Based Management Protocol for Clinicians

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Acute Liver Failure in Adults: an Evidence- Based Management Protocol for Clinicians Acute Liver Failure in Adults: An Evidence- Based Management Protocol for Clinicians Heather Patton, MD, Michael Misel, PharmD, and Robert G. Gish, MD Dr. Patton is an Assistant Clinical Abstract: With the goal of providing guidance on the provision Professor of Medicine in the Division of optimal intensive care to adult patients with acute liver fail- of Gastroenterology at the University ure (ALF), this paper defines ALF and describes a protocol for of California (UC) San Diego School of appropriately diagnosing this relatively rare clinical entity and Medicine; she is also affiliated with the ascertaining its etiology, where possible. This paper also identi- Center for Hepatobiliary Disease and fies the few known therapies that may be effective for specific Abdominal Transplantation (CHAT) in the UC San Diego Health System, both causes of ALF and provides a comprehensive approach for antici- in San Diego, California. Dr. Misel is an pating, identifying, and managing complications. Finally, one of Assistant Clinical Professor at the UC the more important aspects of care for patients with ALF is the San Diego Skaggs School of Pharmacy determination of prognosis and, specifically, the need for liver & Pharmaceutical Sciences; he is also a transplantation. Prognostic tools are provided to help guide the Pharmacist Specialist in Hepatobiliary clinician in this critical decision process. Management of patients Disease and Abdominal Transplant at CHAT in the UC San Diego Health with ALF is complex and challenging, even in centers where staff System. Dr. Gish is Chief of Clinical members have high levels of expertise and substantial experience. Hepatology and a Professor of Clinical This evidence-based protocol may, therefore, assist in the delivery Medicine in the Division of Gastroen- of optimal care to this critically ill patient population and may terology at the UC San Diego School of substantially increase the likelihood of positive outcomes. Medicine; he is also Medical Director of CHAT in the UC San Diego Health System. ue to the complexity of clinical care for patients with acute Address correspondence to: and chronic liver disease, evidence-based protocols provide Dr. Heather Patton a means to improve delivery of care. This is particularly Dtrue when multiple specialties are involved in the care team, when 200 West Arbor Drive, MC 8413 San Diego, CA 92103; physician coverage may change day-to-day or week-to-week, and Tel: 619-543-2470; when trainees (medical students, residents, and fellows) comprise Fax: 619-543-2766; part of the care team. The goal of the following protocol is to guide E-mail: [email protected] the provision of optimal intensive care to adult patients with acute liver failure (ALF), both fulminant and subfulminant, who are being managed in hospital wards and in the intensive care unit (ICU). The protocol is designed to help clinicians to define and recognize ALF; to promptly identify its cause, when possible; to identify com- mon complications associated with ALF and appropriate strategies to prevent or manage these complications; and to rapidly triage ALF patients for liver transplantation evaluation and listing, where appropriate. This protocol is intended for the adult patient with Keywords Acute liver failure, liver transplantation, fulminant ALF. Important differences may exist in management of the pedi- liver failure, hepatic encephalopathy, acute-on- atric population, who may present with other signs of ALF without chronic liver failure, intracranial hypertension, overt hepatic encephalopathy (HE); readers are directed to reviews 1,2 coagulopathy specific to this patient population. Gastroenterology & Hepatology Volume 8, Issue 3 March 2012 161 P A T T O N e T A l ALF (fulminant and subfulminant) is a rare but following evaluation is recommended to help determine the serious clinical syndrome characterized by sudden etiology of liver failure. Determination of etiology assists in loss of hepatic function in a person without evidence directing therapy and estimating prognosis. of preexisting liver disease.3 Exceptions to this defini- tion include Wilson disease, reactivation of hepatitis B Medical History virus infection, and autoimmune hepatitis.4 ALF affects First, clinicians should obtain a detailed medical history approximately 2,000–3,000 Americans each year.5 from the patient and/or family, including first onset of Causes of ALF include drug-induced or toxin-induced symptom(s); all medications used over the last 6 months, liver disease, viral hepatitis, metabolic diseases, and including prescription medications, over-the-counter vascular and/or ischemic liver disease; 15–20% of cases agents, herbal supplements, wild mushrooms, or other have no identifiable cause (Table 1). alternative/complementary therapies; a detailed history of Acetaminophen (APAP) is the leading cause of current and prior substance use; current or prior depression ALF. Patients who are at increased risk for APAP- (including assessment of suicidality), anxiety, psychosis, or induced ALF include those with concomitant alcohol other mental illness; viral prodrome; and recent travel. use, malnutrition, or use of medications known to induce CYP450 enzymes (eg, phenytoin, carbamaze- Physical Examination pine, or rifampin). In 308 consecutive patients from Second, a complete physical examination should be per- 17 tertiary care centers participating in the US Acute formed. Particular attention should be paid to the assessment Liver Failure Study Group, APAP was identified as of mental status, the neurologic examination, and the fundo- the etiology of ALF in 40% of patients.6 The other scopic examination in patients with HE of stage 2 or greater. etiologies identified, in ascending order of prevalence, were malignancy (1%), Budd-Chiari syndrome (2%), Laboratory Tests pregnancy (2%), Wilson disease (3%), hepatitis A virus Third, a number of laboratory tests are recommended for infection (4%), autoimmune hepatitis (4%), ischemic the purposes of establishing an etiology and determining hepatitis (6%), hepatitis B virus infection (6%), and prognosis. Tests that should be performed on presentation idiosyncratic drug-induced liver injury (13%); 17% of are listed in Table 3. cases were found to be indeterminate. Additional Tests to Consider Definition of Acute Liver Failure In patients with ALF of unknown etiology (“sero- negative” ALF), additional laboratory studies to con- ALF is manifest by the presence of coagulopathy (inter- sider include autoimmune marker tests (antinuclear national normalized ratio [INR] >1.5) and any degree of antibody, anti-actin antibody, quantitative immuno- encephalopathy occurring within 24 weeks of the first globulins, and anti–soluble liver antigen); hepatitis E onset of symptoms in patients without underlying liver virus immunoglobulin (Ig)M testing (in patients with disease.7,8 The particular timing and severity of clinical compatible travel history); and hepatitis C virus poly- presentation may be divided into hyperacute, acute, and merase chain reaction (PCR) if risk factors are present. subacute; the former 2 categories encompass fulminant If Wilson disease is suspected, tests to consider include hepatic failure, while subacute is also termed subfulmi- serum ceruloplasmin, serum copper level, 24-hour nant. These categories can provide clues as to the underly- urine collection for quantitative copper, and slit-lamp ing cause and prognosis of ALF (Table 2). Paradoxically, ophthalmologic evaluation for the presence of Kayser- patients with HE that occurs within 8 weeks of the onset Fleischer rings (these tests should be done in all young of symptoms (fulminant hepatic failure) have a lower patients with ALF and in those with Coombs-negative mortality than those with a more gradually evolving hemolytic anemia, low alkaline phosphatase levels, course. Multiorgan failure is the most common cause of or splenomegaly). If a viral syndrome is identified or death (>50%) from ALF, with intracranial hypertension suspected, consider testing for herpes simplex virus (ICH) and infection accounting for most of the other 1/2 IgM (PCR also available), Epstein-Barr virus PCR, deaths in this patient population.9 cytomegalovirus PCR, adenovirus PCR, and varicella- zoster virus IgM (in the setting of vesicular rash). Diagnosis of Acute Liver Failure There are other diagnostic tests that may also be useful. A diagnostic transjugular liver biopsy should be In patients with suspected ALF (those presenting with considered for all unknown or non-APAP cases. Histol- coagulopathy and HE in the absence of known underlying ogy has not been shown to predict outcomes, although liver disease within a time frame compatible with ALF), the the liver biopsy may help to strategize immunosuppres- 162 Gastroenterology & Hepatology Volume 8, Issue 3 March 2012 A c u T e l I V e r F ai l u r e in A d u lT s Table 1. Differential Diagnosis of Acute Liver Failure (ALF) Category Etiology of ALF Examples and/or common clinical features Viruses Hepatitis A virus Rare in the United States; usually hyperacute in presentation; ALF is more common in older patients or those with underlying liver disease Hepatitis B virus ± delta virus Less common following widespread vaccination Hepatitis E virus Occurs in those with a history of travel to endemic areas or direct exposure to those who have traveled to such areas, as well as those with exposure to porcine farm animals; has a higher risk during pregnancy, especially in the 3rd trimester Herpes simplex
Load more

Recommended publications
  • Tbi): Progress in Treating the Sig- Nature Wounds of the Current Conflicts
    S. HRG. 111–866 OVERSIGHT HEARING ON TRAUMATIC BRAIN IN- JURY (TBI): PROGRESS IN TREATING THE SIG- NATURE WOUNDS OF THE CURRENT CONFLICTS HEARING BEFORE THE COMMITTEE ON VETERANS’ AFFAIRS UNITED STATES SENATE ONE HUNDRED ELEVENTH CONGRESS FIRST SESSION MAY 5, 2010 Printed for the use of the Committee on Veterans’ Affairs ( Available via the World Wide Web: http://www.access.gpo.gov/congress/senate U.S. GOVERNMENT PRINTING OFFICE 64–440 PDF WASHINGTON : 2011 For sale by the Superintendent of Documents, U.S. Government Printing Office Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800 Fax: (202) 512–2104 Mail: Stop IDCC, Washington, DC 20402–0001 VerDate Nov 24 2008 12:21 Feb 28, 2011 Jkt 000000 PO 00000 Frm 00001 Fmt 5011 Sfmt 5011 H:\ACTIVE\050510.TXT SVETS PsN: PAULIN COMMITTEE ON VETERANS’ AFFAIRS DANIEL K. AKAKA, Hawaii, Chairman JOHN D. ROCKEFELLER IV, West Virginia RICHARD BURR, North Carolina, Ranking PATTY MURRAY, Washington Member BERNARD SANDERS, (I) Vermont LINDSEY O. GRAHAM, South Carolina SHERROD BROWN, Ohio JOHNNY ISAKSON, Georgia JIM WEBB, Virginia ROGER F. WICKER, Mississippi JON TESTER, Montana MIKE JOHANNS, Nebraska MARK BEGICH, Alaska SCOTT P. BROWN, Massachusetts ROLAND W. BURRIS, Illinois ARLEN SPECTER, Pennsylvania WILLIAM E. BREW, Staff Director LUPE WISSEL, Republican Staff Director (II) VerDate Nov 24 2008 12:21 Feb 28, 2011 Jkt 000000 PO 00000 Frm 00002 Fmt 5904 Sfmt 5904 H:\ACTIVE\050510.TXT SVETS PsN: PAULIN CONTENTS MAY 5, 2010 SENATORS Page Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii ........................... 1 Burr, Hon.
    [Show full text]
  • Proceedings of Réanimation 2019, the French Intensive Care Society International Congress
    Ann. Intensive Care 2019, 9(Suppl 1):40 https://doi.org/10.1186/s13613-018-0474-7 MEETING ABSTRACTS Open Access Proceedings of Réanimation 2019, the French Intensive Care Society International Congress France. 23–25 January 2019 Published: 29 March 2019 Oral communications Oral communications: Physiotherapists Conclusion: We found that peak expiratory was higher with than with- out collapsible tube. In vivo measurements in patients should be done COK‑1 to confrm this fnding. Bench assessment of the efect of a collapsible tube on the efcacy of a mechanical insufation‑exsufation device Romain Lachal (speaker) Réanimation médicale, Hôpital de la Croix‑Rousse, Hospices Civils de Lyon, Lyon, FRANCE Correspondence: Romain Lachal ‑ [email protected] Annals of Intensive Care 2019, 9(Suppl 1):COK-1 Introduction: Mechanical Insufation-Exsufation (MI-E) by using a specifc device is commonly used to increase weak cough, as in patients with chronic neuromuscular weakness or in intensive care unit (ICU) patients with ICU-acquired neuro-myopathy. The assess- ment of the efcacy of MI-E device is commonly done by measuring peak cough fow (PCF). Upper airways collapse is frequently associated with neuromuscular disease and may compromise MI-E efcacy. Tra- cheomalacia is another disease that may impede PCF to increase with MI-E device. The goal of present study was to carry out a bench study to assess the efect of MI-E on PCF with and without the presence of a collapsible tube. Our hypothesis was that PCF was lower with than without collapsible tube. COK‑2 Patients and methods: We used a lung simulator (TTL Michigan Early verticalization in neurologic intensive care units Instruments) with adjustable compliance (C) and resistance (R) to with a weight suspension system which a MI-E (CoughAssist E70, Philips-Respironics) was attached, Margrit Ascher (speaker), Francisco Miron Duran, Fanny Pradalier, Claire with or without a latex collapsible tube.
    [Show full text]
  • Real and Illusory Perceptions of Patients in Induced Coma
    REVIEW Real and illusory perceptions of patients in induced coma Percepções reais e ilusórias de pacientes em coma induzido Percepciones reales e ilusorias de pacientes en coma inducido ABSTRACT Simone Costa SilvaI Objective: To identify, in the scientific literature, real and illusory perceptions of adult patients in induced coma. Methods: This is an integrative review of 15 primary studies from ORCID: 0000-0001-9220-6310 the Medline, Web of Science, LILACS, CINAHL and SCOPUS databases. Results: The main I memories reported after induced coma were thirst, cold, and pain. In some studies, patients Laura Menezes Silveira reported they were unable to tell whether they were awake or dreaming, whether it was ORCID: 0000-0002-2397-2553 real or unreal. Satisfactory memories were reported by patients related to the care received I and the use of bedside journals. Conclusion: Evidence showed a number of studies aiming Leila Maria Marchi-Alves to identify delirium, but without a focus on analyzing real or illusory perceptions of patients ORCID: 0000-0001-9374-8074 after induced coma. Thus, this integrative review identified scientific evidence of memories related to perceptions of sedated patients in the intensive care unit. I Isabel Amélia Costa Mendes Descriptors: Deep Sedation; Memory; Delirium; Critical Care; Nursing. ORCID: 0000-0002-0704-4319 I RESUMO Simone de Godoy Objetivo: Identificar, a partir da literatura científica, percepções reais e ilusórias de pacientes ORCID: 0000-0003-0020-7645 adultos em coma induzido. Método: Revisão integrativa de 15 estudos primários localizados nas bases de dados Medline, Web of Science, LILACS, CINAHL e SCOPUS. Resultados: As principais memórias relatadas após o coma induzido são sede, frio e dor.
    [Show full text]
  • Coma, Delirium, and Cognitive Dysfunction in Critical Illness Robert D
    Crit Care Clin 22 (2007) 787–804 Coma, Delirium, and Cognitive Dysfunction in Critical Illness Robert D. Stevens, MD*, Paul A. Nyquist, MD, MPH Departments of Anesthesiology/Critical Care Medicine, Neurology, Neurological Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA Syndromes of global cerebral dysfunction associated with critical illness include acute disorders such as coma and delirium, and chronic processes namely cognitive impairment. These syndromes can result from direct cere- bral injury, but in many instances develop as a complication of a systemic in- sult such as cardiac arrest, hypoxemia, sepsis, metabolic derangements, and pharmacological exposures. Coma frequently evolves into phenomenologi- cally distinct disorders of consciousness such as the vegetative state and the minimally conscious state, and it must be differentiated from conditions in which consciousness is preserved, as in the locked-in state. Coma and de- lirium are independently associated with increased short-term mortality, while cognitive impairment has been linked to the poor long term functional status and quality of life observed in critical illness survivors. Advances have been made in defining, scoring, and delineating the epidemiology of cerebral dysfunction in the intensive care unit, but research is needed to elucidate underlying mechanisms, with the goal of identifying targets for prevention and therapy. Acute brain dysfunction A high proportion of patients who are admitted to the ICU develops a global alteration in cognitive function that is associated with an underlying cerebral process that can be structural or metabolic [1,2]. Terms that are used commonly to describe these disturbances include coma, delirium, encephalop- athy, acute confusional state, organic brain syndrome, acute organic reaction, * Corresponding author.
    [Show full text]
  • Types of Brain Dysfunction in Critical Illness Robert D
    Neurol Clin 26 (2008) 469–486 Types of Brain Dysfunction in Critical Illness Robert D. Stevens, MD*, Paul A. Nyquist, MD, MPH Departments of Anesthesiology Critical Care Medicine, Neurology, and Neurological Surgery, Johns Hopkins University School of Medicine, Meyer 8-140, 600 North Wolfe Street, Baltimore, MD 21287, USA Many patients in the ICU develop a global alteration in cognitive func- tion that may be structural or metabolic in origin [1]. Terms used to describe these disturbances include delirium, acute confusional state, organic brain syndrome, acute organic reaction, cerebral insufficiency, brain failure, ICU psychosis, and encephalopathy. Etiology-specific terms, such as septic encephalopathy or hepatic encephalopathy, have been used when there is a strong presumption regarding the causative mechanism. It has been pos- tulated that many of these disorders are clinical expressions of a pathophys- iologic spectrum, collectively referred to as ‘‘critical illness brain syndrome’’ [2], ‘‘critical illness–associated cognitive dysfunction’’ [3], or ‘‘critical illness encephalopathy’’ [1]. Recently, there has been an effort to rationalize this terminology and to classify brain dysfunction in the ICU as either delirium or coma, using validated clinical criteria [4–7]. Coma Clinical assessment In the clinical realm consciousness is described in terms of two primary neurologic functions: arousal or wakefulness, and awareness of self and of the environment [8]. Awareness is the content of consciousness and includes multiple cognitive domains including perception, attention, memory, This is an updated version of an article that originally appeared in Critical Care Clinics, volume 22, issue 4. * Corresponding author. Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Meyer 8-140, 600 North Wolfe Street, Baltimore, MD 21287.
    [Show full text]
  • Let's Talk About Hospital Treatment Options During the COVID-19
    Let’s Talk About Hospital Treatment Options During the COVID-19 Pandemic This information can help you get informed and plan ahead if you ever become seriously ill from COVID-19 WHAT WE KNOW ABOUT PEOPLE WHO GET SICK WITH COVID-19 n Most people with COVID-19 recover on their own while self-isolating at home n Older adults and people with a few medical conditions are more likely to become seriously ill with COVID-19 and have a higher risk of dying n There is currently no cure for COVID-19; the goal of treatment is to give the body the chance to fight the virus by building the immune system n A small number of people become sick enough to need care in a hospital n A few become very seriously ill and go to an intensive care unit (ICU) WHY ARE PEOPLE SERIOUSLY ILL WITH COVID-19 TREATED WITH A BREATHING MACHINE (VENTILATOR)? HOW WELL DOES A BREATHING MACHINE (VENTILATOR) WORK? n People seriously ill with COVID-19 find it difficult to breathe on their own n Most people sick with COVID-19 who are put on a ventilator do not live n The ventilator might keep the person alive long enough for the body to fight the disease n Those who survive may never return to their previous health HOW DOES A VENTILATOR WORK? (SEE ABOVE RIGHT) n The longer people are on a ventilator, the more likely n A ventilator pushes air through a tube directly into a they will need help with everyday living after the person’s lungs ventilator is removed n The tube is inserted down the throat so the person cannot talk WHAT IS CARDIOPULMONARY RESUSCITATION (CPR)? n CPR is used in an emergency if the person stops n People on a ventilator are given strong medicine to breathing or the heart stops beating.
    [Show full text]
  • Factsheet COMA and REDUCED ALERTNESS
    Factsheet COMA AND REDUCED ALERTNESS COMA AND UNCONSCIOUSNESS After a traumatic injury a patient may be unconscious for some time. This can be due to different reasons. If a patient is very unwell they may go to critical care/intensive care. There they may be placed in a medically induced coma while they get better. This is called sedation with medication. Once a patient is more stable the doctors will reduce the medication to try and wake up a patient. Some patients with head injuries they may not wake up immediately, and in some cases they could remain, which looks to be asleep, for a long time after leaving intensive care. If someone does not ‘wake up’ they may be diagnosed with prolonged disorders of consciousness. This diagnosis will only be given after several months of the patient not responding to people or sounds around them even if their eyes may be open at times. REDUCED AWARENESS, DISORIENTATION AND CONFUSION Some patients are very confused after a traumatic injury. This can be due to a head injury, the medication they received, such as sedation in critical care, or the shock from the accident. The medical team and therapy team will assess a patient to determine what could be the cause of the confusion. There is a tool called the Rancho Los Amigos scale that is used in some centres which helps to explain the behaviour of patients. POST TRAUMATIC AMNESIA (PTA) Some patients with a head injury may be in post-traumatic amnesia (PTA). This is a period after the injury where they are confused and agitated.
    [Show full text]
  • Critical Care Model
    Critical Care Model CCrriiittiiiccaalll CCaarree EE//MM MMooddeelll 66//1166//0033 Critical Care Interventions The following interventions qualify as critical care. Additional explanations, examples and clarifications appear in italics. Items below as performed by hospital staff, rather than physician Interventions/care for critically ill or critically injured Examples of critical ill or critically injured patients include: patients, e.g. central nervous system failure, circulatory cardiopulmonary arrest or near arrest related to primary cardiac failure, shock, renal, hepatic, metabolic, and/or or respiratory causes, drug overdose, hyper/hypo-thermia, trauma respiratory failure. This may include, but is not limited (including severe burns), and other shock events such as to the following interve ntions: anaphylaxis, diabetic shock, internal bleeding sepsis, etc. Assist in induction/monitoring of pharmaceutical - Examples: barbiturate coma for status epilepticus induced coma Assist with rapid sequence intubation (that with Examples: AMBU, frequent ETT suctioning, set up for tube provision/administration of sedative and/or paralytic thoracostomy and assist physician with procedure, assist physician agents), and/or airway management in performance of emergent cricothyrotomy, tracheostomy, endotracheal intubation, chest tube insertion, or any other emergency airway. Code team/crash team/trauma team intervention Multidisciplinary team approach to life or limb threatening situation. Some of the interventions will be separately billable, but
    [Show full text]
  • Acute Poisoning Induced Coma: Characteristics and Predictive Role of Early Creatine Phosphokinase on Its Outcome
    Ain Shams Journal of Forensic Medicine and Clinical Toxicology Jan 2019, 32: 1-9 Acute Poisoning Induced Coma: Characteristics and Predictive Role of Early Creatine Phosphokinase on Its Outcome Eman Abdelfath Mohammed1 and EL -Sayed Hamdey EL-Sayed Gawesh2 1 Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Ain Shams University. 2 Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Al- Azhar University. Cairo, Egypt. All rights reserved. Abstract: Background: Emergency physicians are often challenged with a comatose patient; 30% of patients with coma of unknown origin are due to intoxication. Comatose patients are at high risk for morbidity and mortality. Objective: The present study assessed poisoning-induced coma regarding demographic and intoxication data, causative agents, clinical data, management modalities and outcome. In addition to evaluation of the role of creatine phosphokinase (CPK) level on admission and other variables as predictive factors for the outcome in toxic coma. Subjects and Methods: This study was conducted prospectively on one hundred comatose intoxicated patients, admitted to Poison Control Center Ain Shams University Hospitals (PCCASU). Results: The majority of patients (64%) were in the age group 18-40 year, and there was male predominance (56%). Organophosphorus, carbamazepine and tramadol were the most common toxic agents inducing coma. Death rate was 12% and mortality is much higher in patients with older age, elevated admission creatine phosphokinase, longer duration of hospital stay and higher grade of Reed’s classification of coma. Conclusion: Organophosphorus followed by carbamazepine and tramadol were the most common toxic agents inducing coma. Older age, elevated admission creatine phosphokinase, longer duration of hospitalization and higher grade of Reed’s classification of coma can predict the mortality.
    [Show full text]
  • Changes in the Propofol-Induced Frontal Electroencephalogram in Children with Autism Spectrum Disorder
    Changes in the Propofol-Induced Frontal Electroencephalogram in Children With Autism Spectrum Disorder The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Walsh, Elisa Claire. 2017. Changes in the Propofol-Induced Frontal Electroencephalogram in Children With Autism Spectrum Disorder. Doctoral dissertation, Harvard Medical School. Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:32676116 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA TABLE OF CONTENTS ACKNOWLEDGMENTS .................................................................................................. 2! ABBREVIATIONS ............................................................................................................ 4! ABSTRACT ...................................................................................................................... 5! INTRODUCTION ............................................................................................................. 6! Overview of General Anesthesia (GA) ................................................................................... 6! Molecular and Neural Circuit Mechanisms of Propofol ...................................................... 6! Use of the Electroencephalogram in GA and Brain Monitoring ........................................
    [Show full text]
  • Prophylactic Haloperidol Effects on Long-Term Quality of Life In
    CRITICAL CARE MEDICINE ABSTRACT Background: Delirium incidence in intensive care unit patients is high and associated with impaired long-term outcomes. The use of prophylactic halo- peridol did not improve short-term outcome among critically ill adults at high Prophylactic Haloperidol risk of delirium. This study evaluated the effects of prophylactic haloperidol use on long-term quality of life in this group of patients and explored which Effects on Long-term factors are associated with change in quality of life. Methods: A preplanned secondary analysis of long-term outcomes of the Quality of Life in Critically pRophylactic haloperidol usE for DeliriUm in iCu patients at high risk for dElirium (REDUCE) study was conducted. In this multicenter randomized Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/131/2/328/377461/20190800_0-00022.pdf by guest on 29 September 2021 Ill Patients at High Risk clinical trial, nondelirious intensive care unit patients were assigned to pro- phylactic haloperidol (1 or 2 mg) or placebo (0.9% sodium chloride). In all for Delirium groups, patients finally received study medication for median duration of 3 days [interquartile range, 2 to 6] until onset of delirium or until intensive care Results of the REDUCE Study unit discharge. Long-term outcomes were assessed using the Short Form-12 questionnaire at intensive care unit admission (baseline) and after 1 and 6 Paul J. T. Rood, R.N., M.Sc., Marieke Zegers, Ph.D., months. Quality of life was summarized in the physical component summary Arjen J. C. Slooter, M.D., Ph.D., Albert Beishuizen, M.D., Ph.D., and mental component summary scores.
    [Show full text]
  • Management of Cerebral Edema in Acute Liver Failure
    821 Management of Cerebral Edema in Acute Liver Failure Beverley Kok, MBBS1 Constantine J. Karvellas, MD, SM1 1 Division of Gastroenterology (Liver Unit), Department of Critical Address for correspondence Constantine J. Karvellas, MD, SM, FRCPC, Care Medicine, University of Alberta, Edmonton, Canada Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, 1-40 Zeidler Ledcor Building, Semin Respir Crit Care Med 2017;38:821–829. Edmonton, Alberta T6G-2Â8, Canada (e-mail: [email protected]). Abstract Advances in medical care of the acute liver failure patient have led to a significant Keywords reduction in mortality related to the condition. Nevertheless, cerebral edema and ► acute liver failure ensuing brain herniation remains one of the top causes of demise in acute liver failure. ► intracranial Controversy remains regarding the utility of invasive intracranial pressure monitoring hypertension as well as usage of novel treatment modalities including therapeutic hypothermia. This ► cerebral edema review provides a brief summary into the pathophysiology and risk factors for ► neuroprotection developing cerebral edema in the context of acute liver failure; this review particularly ► therapeutic provides a practical focus on general management of the patient with established hypothermia cerebral edema as well as specific intracranial pressure-lowering strategies. Acute liver failure (ALF) is a condition wherein a patient with Europe) over a 35-year period showed the proportion of ALF a
    [Show full text]