2023 FSA Podium and Poster Abstracts

P076: AGAINST THE ODDS: SUCCESSFUL LIVER TRANSPLANT IN A PATIENT WITH ACUTE LIVER FAILURE AND INTRACEREBRAL HEMORRHAGE
Sindhura Sharma Bhat; Yosaf Zeyed; Eslam Fouda; Massud Turbay; Gabriela Guanchez; Ramona Nicolau; Fouad Souki; Jackson Memorial Hospital/University of Miami Miller School of Medicine

Introduction: Acute liver failure (ALF) is a serious condition with a high risk of morbidity and mortality. In the United States, drug-induced hepatitis is responsible for 50% of cases of ALF, with acetaminophen being the most common cause. We present a unique case of ALF induced by acetaminophen, complicated by hepatic encephalopathy and severe intracranial hemorrhage, which was successfully treated with emergency liver transplantation.

Case presentation: A 45-year-old woman with history of recent abdominoplasty and breast augmentation presented with grossly elevated liver function tests and was diagnosed with ALF caused by high doses of acetaminophen. She was admitted to the ICU, intubated, started on pressors, continuous hemodialysis and transfusions. Her Na-MELD score was 32. Although her initial brain CT was unremarkable, follow-up imaging revealed multiple bilateral frontoparietal parenchymal hemorrhages with associated edema, mass effect, and rightward midline shift of 3 mm. Despite all interventions, there was a worsening in cerebral imaging, with enlargement of intracranial hemorrhage and an increasing midline shift to 4.3 mm. As a result, she was listed for liver transplantation as a Status IA.

During the liver transplant surgery, multiple vascular accesses were established using 9Fr/12 Fr multi-lumen internal jugular vein catheters, a 12 Fr femoral vein catheter, and bilateral radial arterial lines. Renal replacement therapy was continued during the procedure. Several measures like head elevation, coagulation management, assessment of optic nerve sheath diameter, hyperventilation to maintain a PaCO2 of 30 mmHg, diuresis, and fluid restriction were taken intraoperatively to prevent further intracranial hemorrhage and maintain cerebral perfusion pressure. Volume status and cardiac function were monitored with transesophageal echocardiography (TEE) and Flotrac. Pressors, such as norepinephrine and vasopressin were used to maintain blood pressure. The patient received 2.5 liters of crystalloids, 1 liter of 5% albumin, and 27 units of blood transfusion. The estimated blood loss was 5 liters.

The surgery was successfully completed; however, postoperatively the patient had worsening intracranial hemorrhage, edema and midline shift which necessitated placement of fiberoptic intracranial bolt for pressure monitoring and external ventricular drain. The patient had progressive neurological improvement, extubated on POD 7, and discharged home POD 65 after physical and rehabilitation therapy.

Discussion: Liver transplantation in patients with ALF, cerebral edema, and intracranial hemorrhages requires a multidisciplinary approach with special perioperative considerations. Preoperatively, the decision to proceed with liver transplantation should be made based on the patient's overall condition and the potential benefits versus the risks. This unique case demonstrates that despite a poor prognosis, our patient was listed and underwent liver transplantation successfully. During the transplant surgery, maintaining sodium levels between 150-155 meq/L, mild hypothermia, coagulopathy treatments, prompt use of inotropes to keep cerebral perfusion pressures above 65 mm Hg are crucial. In addition to measures that minimize brain injury, immediate postoperative care should include repeat CT scans of the brain, monitoring of intracranial pressure, and neurosurgical interventions as needed.

Conclusions: In patients with drug-induced ALF, prompt liver transplantation can lead to a successful outcome, even in the presence of hepatic encephalopathy, cerebral edema and multiple intracranial hemorrhages.