Vol 5 | Issue 1 | Jan-April 2019 | page: 18-20 | Anupam Raj, Vijay Shankar, Meera Kharbhanda, Neerav Goyal
Authors: Anupam Raj , Vijay Shankar , Meera Kharbhanda , Neerav Goyal .
 Department of Anaesthesia, Indraprastha Apollo Hospital New Delhi
 Dept Of Liver Transplantation , I ndraprastha Apollo Hospital New Delhi
Address of Correspondence
Dr. Anupam Raj,
Department of Anaesthesia, Indraprastha Apollo Hospital New Delhi
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.
Keywords: Acute Liver Failure, Cerebral Edema, Pregnancy, Hepatitis E, Liver Transplant, Continuous Renal Replacement Therapy
1. Mukherjee KK, Chhabra R, Khosla VK. Raised intracranialpressure in hepatic encephalopathy. Indian J Gastroenterol2003;22(suppl 2):S62–S65.
2. Keays RT1, Alexander GJ, Williams R. The safety and value of extradural intracranial pressure monitors in fulminant hepatic failure. J Hepatol. 1993 Jun;18(2):205-9
3. Vaquero J1, Fontana RJ, Larson AM, Bass NM, Davern TJ, Shakil AO, Han S, Harrison ME, Stravitz TR, Muñoz S, Brown R, Lee WM, Blei AT. Complications and use of intracranial pressure monitoring in patients with acute liver failure and severe encephalopathy. Liver Transpl. 2005 Dec;11(12):1581-9
4. Stravitz RT, Kramer AH, Davern T, Shaikh AO, Caldwell SH, Mehta RL, et al.; for Acute Liver Failure Study Group. Intensive care of patients with acute liver failure:recommendations of the U.S. Acute Liver Failure StudyGroup. Crit Care Med 2007;35:2498–2508.
5. Rajajee V, Vanaman M, Fletcher JJ, Jacobs TL. Optic nerve ultrasound for the detection of raised intracranial pressure. Neurocrit Care 2011;15:506–515.
6. Cammarata G, Ristagno G, Cammarata A, Mannanici G, Denaro C, Gullo A. Ocular ultrasound to detect intracranial hypertension in trauma patients. J Trauma 2011;71:779–781
7. Clemmesen JO, Larsen FS, Kondrup J, Hansen BA, Ott P: Cerebral herniation in patients with acute liver failure is correlated with arterial ammonia concentration. Hepatology 29: 648–653, 1999
8. Warrillow SJ, Bellomo R: Preventing cerebral oedema in acute liver failure: The case for quadruple-H therapy. Anaesth Intensive Care 42: 78–88, 2014
9. Cordoba J, Blei AT, Mujais S: Determinants of ammonia clearance by hemodialysis. Artif Organs 20: 800–803, 1996
10. Hansen HC, Helmke K. Validation of the optic nerve sheath response to changing cerebrospinal fluid pressure: ultrasound findings during intrathecal infusion tests. J Neurosurg1997;87:34–40.
11. Helmke K, Hansen HC. Fundamentals of transorbital sonographic evaluation of optic nerve sheath expansion under intracranial hypertension. I. Experimental study. PediatrRadiol1996;26:701–705
12. Jalan R et al. Moderate hypothermia prevents cerebral hyperaemia and increase in intracranial pressure in patients undergoing liver transplantation for acute liver failure. Transplantation 2003;75(12):2034-9
13. Lai Y-C, Huang H-P, Tsai I-J, Tsau Y-K: High-volume continuous venovenous hemoﬁltration as an effective therapy for acute management of inborn errors of metabolism in young children. Blood Purif 25: 303–308, 2007
14. BernalW,LeeWM,WendonJ,LarsenFS,WilliamsR:Acuteliver failure: A curable disease by 2024? J Hepatol 62[Suppl]: S112– S120, 2015
15. Slack AJ, Auzinger G, Willars C, Dew T, Musto R, Corsilli D, Sherwood R, Wendon JA, Bernal W: Ammonia clearance with haemoﬁltrationinadultswithliverdisease.LiverInt34:42–48,2014
16. Warrillow SJ, Bellomo R: Preventing cerebral oedema in acute liver failure: The case for quadruple-H therapy. Anaesth Intensive Care 42: 78–88, 2014
|How to Cite this Article: Raj A, Shankar V, Kharbhanda M, Goyal N. Peri-Operative monitoring of Optic Nerve Sheath Diameter & early initiation of Renal Replacement Therapy helps in rapid Post-Operative recovery in a patient with Acute Liver Failure post Liver Transplant. Journal of Anaesthesia and Critical Care Case Reports Jan-April 2019;5(1):18-20.|