Multidisciplinary Management of Cerebral Edema Associated with Fulminant Hepatic Encephalopathy in a Neurosciences Intensive Care Unit (P6.004)

OBJECTIVE: To report a novel multidisciplinary treatment approach for cerebral edema associated with fulminant hepatic encephalopathy (FHE). BACKGROUND: FHE-associated cerebral edema has dismal prognosis if transplantation is excluded DESIGN/METHODS: We reviewed all cases of FHE admitted to our hospital since 2008. In 2010 we developed a multidisciplinary management protocol implemented only in the Neurosciences-ICU (NICU) and mandating transfer of patients entering FHE grade 3 from other Intensive Care Units (ICUs) to the NICU for treatment of cerebral edema. Multiple interventions were utilized including coagulopathy reversal with Factor VII and prothrombin complex concentrate (PCC), intracranial pressure (ICP) device placement, osmotherapy, aggressive ammonia lowering regimen, early renal replacement therapy and mild hypothermia for refractory ICP. RESULTS: Seventeen patients (15 women, mean age of all patients 41 years) were admitted; six were managed in the ICUs (2/6 before 2010) and 11 in the NICU (all after 2010). The etiology of FHE was acetaminophen toxicity in 70.5% of patients. The admission Model for End-Stage Liver Disease (MELD) scores and liver enzymes were similar in the ICUs and NICU. Although the NICU admission ammonia level was higher than in the other ICUs (169.5 vs 107.5 mcmol/L, p = 0.078), nadir ammonia was lower in the NICU (42.4 vs 79 mcmol/L, p = 0.037, Mann-Whitney). The post-coagulation reversal INR was corrected (mean 3.8 before vs 1.2 after, p = 0.008, Wilcoxon test) and allowed ICP monitoring device placement (in 10/11 NICU and 2/6 ICUs patients) with highest ICP recorded 111 mm Hg. Four NICU patients received hypothermic treatment. Two out of 4 NICU transplant candidates were transplanted, compared to 0/2 in the other ICUs. Mortality was 83.3% (5/6) and 36.4% (4/11), p = 0.13 (Fisher’s test) in the ICUs and NICU, respectively. CONCLUSIONS: A multidisciplinary approach including novel interventions and aiming at cerebral edema protocol-driven management may improve FHE outcomes. Study Supported by: Disclosure: Dr. Varelas has received personal compensation for activities with UCB Pharma as an advisory board member. Dr. Varelas has held stock and/or stock options in The Medicines Company. Dr. Ramadan has nothing to disclose. Dr. Mehta has nothing to disclose. Dr. Hawley has nothing to disclose. Dr. Abdelhak has nothing to disclose. Dr. Rehman has nothing to disclose.