Background: The optimal arterial carbon dioxide tension (P a CO 2 ) in patients with acute bacterial meningitis (ABM) is unknown and controversial. The objective of this study was to measure global cerebral blood flow (CBF), cerebrovascular CO 2 reactivity (CO 2 R), and cerebral metabolic rates (CMR) of oxygen (O 2 ), glucose (glu), and lactate (lac), in patients with ABM and compare the results to those obtained in healthy volunteers. Methods: We studied 19 patients (17 of whom were sedated) with ABM and eight healthy volunteers (controls). CBF was measured during baseline ventilation and hyperventilation with single‐photon emission computed tomography (SPECT) (14 patients) and/or the Kety‐Schmidt technique (KS) (11 patients and all controls). In KS studies, CMR was measured by multiplying the arterial to jugular venous concentration difference (a‐v D) by CBF. Results: CBF did not differ significantly among groups, although a larger variation was seen in patients than in controls. CO 2 R was not significantly different among groups. At baseline, patients had significantly lower a‐v DO 2 , CMR(O 2 ), CMR(glu), and CMR(lac) than controls. CMR(O 2 ) did not change between hyperventilation compared to baseline ventilation, whereas CMR(glu) increased. Conclusion: In patients with acute bacterial meningitis, we found variable levels of CBF and cerebrovascular CO 2 reactivity, a low a‐v DO 2 , low cerebral metabolic rates of oxygen and glucose, and a cerebral lactate efflux. In these patients, a ventilation strategy guided by jugular bulb oximetry and/or repeated CBF measurements may be more optimal in terms of cerebral oxygenation than a strategy aiming at identical levels of P a CO 2 for all patients.
Liver failure is a life-threatening condition, and an artificial liver is highly desirable to replace the failing liver-functions in the waiting time for liver regeneration to happen or until liver transplantation can be undertaken. This review focuses on the efficacy of using artificial extracorporeal liver support devices.Artificial liver support devices such as the molecular adsorbent recirculating system (MARS), fractionated plasma separation and adsorption, and therapeutic plasma exchange (TPE) are well tolerated. MARS and TPE improve systemic haemodynamics and the grade of hepatic encephalopathy. However, randomized, controlled trials of MARS and fractionated plasma separation and adsorption have failed to show improvement in survival in patients with acute liver failure (ALF) and patients with acute-on-chronic liver failure (ACLF). Only TPE improves survival in patients with ALF by ameliorate the release of ammonia, damage-associated molecular patterns and sB7 (CD80/86) from the necrotic liver. No randomized, controlled trials on survival in patients with ACLF using TPE have been done.Liver support systems such as MARS and TPE may temporarily improve systemic haemodynamics and the degree of encephalopathy. However, TPE is the only procedure that improves survival in patients with ALF. The role of TPE in ACLF remains unknown.
In patients with acute liver failure, cerebral herniation is a common cause of death. The present study reports the effect of indomethacin on four occasions of intracranial hypertension, in a 23-year old previously healthy woman with severe acetaminophen poisoning. During each episode of intracranial hypertension, the patient was treated with 25 mg of indomethacin, and each time the intracranial pressure normalized. We recommend further controlled studies to determine the exact effect of indomethacin on cerebral blood flow and metabolism before it is recommended for treatment of intracranial hypertension in patients with acute liver failure.
(1999). The Effect of Increasing Blood Pressure with Dopamine on Systemic, Splanchnic, and Lower Extremity Hemodynamics in Patients with Acute Liver Failure. Scandinavian Journal of Gastroenterology: Vol. 34, No. 9, pp. 921-927.
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