Acetaminophen Intoxication with Fulminant Hepatic Failure Salvaged by Plasmapheresis

Introduction Acetaminophen-induced liver injury is the most common cause of acute liver failure, where multiple ingestions or a delay in the presentation may lead to a poor prognosis. N-acetylcysteine (NAC) is the conventional antidote used to treat acute acetaminophen toxicity, and plasmapheresis can be used as an adjunct, though there are no systematic studies to prove its effectivity. Case Presentation An 18-year-old girl was admitted with reduced responsiveness for one day with a few episodes of diarrhea. On admission, she was febrile and had a GCS of 10/15, otherwise normal neurology. She had marked right hypochodrial tenderness, deep icterus, and a pulse of 120 beats per minute, with a blood pressure of 80/50 mmHg; fluid resuscitation with inotropic support was done. Initial investigations revealed severe metabolic acidosis, hemoglobin of 9.5 g/dL, white blood cell count 13,500/mm3, and platelet 119,000 per µL. The prothrombin time (PT) international normalized ratio (INR) was 4.7, and the activated partial thromboplastin time (APTT) was 38.6. The alanine aminotransferase (ALT) level was 8118 U/L, and aspartate aminotransferase (AST) was 3883 U/L with a total bilirubin of 107 µmol/L. The diagnosis of acute liver failure following acetaminophen intoxication was made and managed with intravenous NAC, pantoprazole cover, intravenous ceftriaxone, metronidazole, thiamine, and vitamin K. Fresh frozen plasma and platelets were given for severe coagulopathy. She was started with plasmapheresis at the intensive care unit (ICU), where she had a significant improvement, though she developed hospital-acquired pneumonia, which was successfully managed. Subsequently, her liver functions returned to the baseline, and she was discharged after a psychiatric assessment. Conclusion A high degree of suspicion needs to be adopted to diagnose acetaminophen-induced acute liver failure when a patient presents with hepatic encephalopathy, and plasmapheresis can be considered a life-saving measure adjunct to the NAC.

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Dengue fever complicated with acute liver failure: A case report of expanded dengue syndrome and literature review

SAGE Open Medical Case Reports ◽

10.1177/2050313x20913428 ◽

2020 ◽

Vol 8 ◽

pp. 2050313X2091342 ◽

Cited By ~ 1

Author(s):

Navaneethakrishnan Suganthan ◽

Gajawathana Sakthilingham ◽

Thirunavukarasu Kumanan

Keyword(s):

Liver Failure ◽

Acute Liver Failure ◽

Dengue Fever ◽

Dengue Infection ◽

Dengue Shock Syndrome ◽

Acute Hepatic Failure ◽

Fresh Frozen Plasma ◽

Uneventful Recovery ◽

Fresh Frozen ◽

Plasma Leakage

Dengue is the most common arboviral disease, the presentation of which ranges from asymptomatic illness to dengue shock syndrome. Liver is the most common organ affected in dengue, and liver involvement is asymptomatic in majority. Dengue fever is a rare, but a leading cause for acute liver failure in endemic regions. Here, we report a case of a 34-year-old male ethanol user (16 units per week), presented with typical features of dengue infection, which was confirmed serologically, complicated with acute liver failure without clinical, radiological or laboratory evidence of plasma leakage. He was managed with intravenous fresh frozen plasma and N-acetyl cysteine along with other recommended supportive therapies for acute hepatic failure. He made an uneventful recovery.

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Hepatitis B-associated Acute Liver Failure: Life-saving Immediate Treatment with Entecavir Inhibits the Replication of Hepatitis B Virus and its Sequelae

Zeitschrift für Gastroenterologie ◽

10.1055/s-0029-1191928 ◽

2009 ◽

Vol 47 (01) ◽

Author(s):

A Canbay ◽

I Gawlista ◽

C Jochum ◽

R Gieseler ◽

M Schlattjan ◽

...

Keyword(s):

Hepatitis B Virus ◽

Hepatitis B ◽

Liver Failure ◽

Acute Liver Failure ◽

Life Saving ◽

B Virus ◽

Failure Life

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Wilson Disease-Induced Acute Liver Failure (NWI = 13) Salvaged without Liver Transplant by Plasmapheresis

Journal of Child Science ◽

10.1055/s-0041-1731079 ◽

2021 ◽

Vol 11 (01) ◽

pp. e145-e147

Author(s):

Nida Mirza ◽

Ravi Bharadwaj ◽

Smita Malhotra ◽

Anupam Sibal

Keyword(s):

Liver Transplantation ◽

Liver Failure ◽

Acute Liver Failure ◽

Wilson Disease ◽

Prognostic Score ◽

Prognostic Index ◽

Kidney Injury ◽

Copper Metabolism ◽

Life Saving ◽

The Brain

AbstractWilson disease (WD) is a disorder of copper metabolism resulting in accumulation of copper in vital organs of the human body, predominantly in the liver and the brain. Acute liver failure in WD has a bad prognosis, especially with a score ≥11 in the revised WD prognostic index; emergency liver transplantation is considered the only life-saving option in this scenario. Here, we reported a girl patient with WD-induced liver failure and poor prognostic score who was rescued by plasmapheresis. She also manifested severe Coombs negative hemolytic anemia and acute kidney injury. This case report highlights the utility of an adjunctive modality besides liver transplantation for the management of fulminant liver failure caused by WD.

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Concurrent Spontaneous Sublingual and Intramural Small Bowel Hematoma due to Warfarin Use

Case Reports in Emergency Medicine ◽

10.1155/2015/583869 ◽

2015 ◽

Vol 2015 ◽

pp. 1-3 ◽

Cited By ~ 1

Author(s):

Gül Pamukçu Günaydın ◽

Hatice Duygu Çiftçi Sivri ◽

Serkan Sivri ◽

Yavuz Otal ◽

Ayhan Özhasenekler ◽

...

Keyword(s):

Emergency Department ◽

Small Bowel ◽

Warfarin Therapy ◽

International Normalized Ratio ◽

Fresh Frozen Plasma ◽

Close Monitoring ◽

Observation Unit ◽

Fresh Frozen ◽

Tomography Scan ◽

Frozen Plasma

Introduction. We present a case of concurrent spontaneous sublingual and intramural small bowel hematoma due to warfarin anticoagulation.Case. A 71-year-old man presented to the emergency department complaining of a swollen, painful tongue. He was on warfarin therapy. Physical examination revealed sublingual hematoma. His international normalized ratio was 11.9. The computed tomography scan of the neck demonstrated sublingual hematoma. He was admitted to emergency department observation unit, monitored closely; anticoagulation was reversed with fresh frozen plasma and vitamin K. 26 hours after his arrival to the emergency department, his abdominal pain and melena started. His abdomen tomography demonstrated intestinal submucosal hemorrhage in the ileum. He was admitted to surgical floor, monitored closely, and discharged on day 4.Conclusion. Since the patient did not have airway compromise holding anticoagulant, reversing anticoagulation, close monitoring and observation were enough for management of both sublingual and spontaneous intramural small bowel hematoma.

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Abstract WP304: Prothrombin Complex Concentrate Rapidly Reverses Coagulopathy but does not Alter Mortality in Warfarin Intracerebral Hemorrhage

Stroke ◽

10.1161/str.44.suppl_1.awp304 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Xuemei Cai ◽

Susannah Orzell ◽

Sarah Suh ◽

Linda Bresette ◽

Farzaneh Sorond ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Vitamin K ◽

Conventional Therapy ◽

Prothrombin Complex Concentrate ◽

International Normalized Ratio ◽

Fresh Frozen Plasma ◽

Thromboembolic Complication ◽

Complication Rates ◽

Significant Difference ◽

Fresh Frozen

INTRODUCTION: Warfarin-associated intracerebral hemorrhage (wICH) remains the most lethal form of iatrogenic stroke. Conventional therapy with fresh frozen plasma (FFP) and intravenous vitamin K takes up to 30 hrs to normalize the international normalized ratio (INR). Prothrombin complex concentrate (PCC) does not require cross-match and is fast acting. We hypothesized that PCC can rapidly reverse coagulopathy and reduce mortality in wICH. Methods: We identified 130 consecutive adult wICH patients over five years from a prospectively collected database. 33 patients were excluded for death or withdrawal of care within 48 hours of admission and 8 patients were excluded for antecedent head trauma, leaving 89 patients for analysis. Forty patients received FFP and vitamin K (conventional therapy) and 49 received PCC in addition to conventional therapy. We compared 6-month mortality, time to INR normalization, quantity of FFP transfused, and thromboembolic complication rates between the two groups. We used logistic regression to adjust for important confounders. Results: PCC-treated and conventional therapy patients had similar distributions of age, sex, co-morbidities, ICH location, initial blood pressure and INR. PCC-treated patients had a higher incidence of intraventicular hemorrhage (IVH) (67% vs 33%). PCC-treated patients required less FFP (mean 6.8 units vs 3.3 units, p<0.0001) and had faster time to INR normalization (mean 3.8 hrs vs 9.8 hrs, p<0.0001). Incidence of ICH expansion was low in both groups. There was no difference in the incidence of deep venous thrombosis and pulmonary embolism (p=0.236) or troponin elevation (p=0.573). There was no significant difference in 6-month mortality (p=0.437) after adjusting for age, ICH location, ICH volume, and presence of IVH. Conclusions: PCC use in wICH was associated with shorter time to INR normalization and reduced FFP transfusion but was not associated with 6-month mortality in this cohort. There was no difference in thromboembolic complication rates between PCC-treated and FFP and vitamin K treated patients. Prospective trials of PCC are necessary to determine if its use can improve morbidity and mortality in wICH and to identify potential subgroups of wICH patients who may benefit from PCC.

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Porcine model characterizing various parameters assessing the outcome after acetaminophen intoxication induced acute liver failure

World Journal of Gastroenterology ◽

10.3748/wjg.v23.i9.1576 ◽

2017 ◽

Vol 23 (9) ◽

pp. 1576 ◽

Cited By ~ 1

Author(s):

Karolin Thiel ◽

Wilfried Klingert ◽

Kathrin Klingert ◽

Matthias H Morgalla ◽

Martin U Schuhmann ◽

...

Keyword(s):

Liver Failure ◽

Acute Liver Failure ◽

Porcine Model ◽

Acetaminophen Intoxication

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Feasibility of a Collaborative, Prospective Interdisciplinary Review and Pharmacy-Based Dispensing Process for Prothrombin Complex Concentrate

Annals of Pharmacotherapy ◽

10.1177/1060028017750397 ◽

2018 ◽

Vol 52 (5) ◽

pp. 454-461 ◽

Cited By ~ 3

Author(s):

Maria Stratton ◽

Philip Grgurich ◽

Kurt Heim ◽

Sandra Mackey ◽

Joseph D. Burns

Keyword(s):

Adverse Events ◽

Prothrombin Complex Concentrate ◽

International Normalized Ratio ◽

Fresh Frozen Plasma ◽

Reversal Agent ◽

Before And After ◽

Measured Time ◽

Fresh Frozen ◽

Warfarin Reversal ◽

Practice Methods

Background: Therapeutic options for rapid reversal of vitamin K antagonist therapy include 4-factor prothrombin complex concentrate (PCC4) and fresh frozen plasma (FFP). These agents have unique requirements for preparation, potential adverse effects, and cost-effectiveness considerations. Objective: To retrospectively assess whether our process for collaborative prospective review and pharmacy preparation facilitates timely and safe warfarin reversal with PCC4 as compared with FFP and to compare effectiveness and safety of the agents in practice. Methods: We performed a retrospective, single-center, before and after cohort study of patients requiring warfarin reversal for life-threatening bleeding or urgent invasive procedures over an 18-month period. The primary end point was time from ordering of reversal agent to administration. Secondary end points measured time to therapeutic effect and rates of adverse events. Results: Of 98 patients studied, 72 received FFP, and 26 received PCC4. The median times from ordering to administration of FFP and PCC4 were 69 and 44 minutes, respectively ( P = 0.015). Median time from ordering to end of infusion was significantly shorter for PCC4 compared with FFP (54 vs 151 minutes, respectively; P < 0.0001). In all, 72% of PCC4 patients and 28% of FFP patients achieved the goal international normalized ratio (INR) of ≤1.4 at the first INR check ( P < 0.0001). Adverse reactions occurred in 4% of patients in each group. Conclusion: In routine clinical practice incorporating collaborative prospective review and dispensing from the institution’s pharmacy, PCC4 was associated with faster administration, a higher rate of INR correction, and similar rates of adverse events compared with FFP.

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Hemostatic Balance in Pediatric Acute Liver Failure: Epidemiology of Bleeding and Thrombosis, Physiology, and Current Strategies

Frontiers in Pediatrics ◽

10.3389/fped.2020.618119 ◽

2020 ◽

Vol 8 ◽

Author(s):

Yonca Bulut ◽

Anil Sapru ◽

Gavin D. Roach

Keyword(s):

Liver Failure ◽

Acute Liver Failure ◽

Cell Activation ◽

Protein S ◽

Bleeding Risk ◽

International Normalized Ratio ◽

Clinical Syndrome ◽

Low Grade ◽

Endothelial Cell Activation ◽

Pediatric Acute Liver Failure

Pediatric Acute Liver Failure (PALF) is a rapidly progressive clinical syndrome encountered in the pediatric ICU which may rapidly progress to multi-organ dysfunction, and on occasion to life threatening cerebral edema and hemorrhage. Pediatric Acute Liver Failure is defined as severe acute hepatic dysfunction accompanied by encephalopathy and liver-based coagulopathy defined as prolongation of International Normalized Ratio (INR) >1.5. However, coagulopathy in PALF is complex and warrants a deeper understanding of the hemostatic balance in acute liver failure. Although an INR value of >1.5 is accepted as the evidence of coagulopathy and has historically been viewed as a prognostic factor of PALF, it may not accurately reflect the bleeding risk in PALF since it only measures procoagulant factors. Paradoxically, despite the prolongation of INR, bleeding risk is lower than expected (around 5%). This is due to “rebalanced hemostasis” due to concurrent changes in procoagulant, anticoagulant and fibrinolytic systems. Since the liver is involved in both procoagulant (Factors II, V, IX, XI, and fibrinogen) and anticoagulant (Protein C, Protein S, and antithrombin) protein synthesis, PALF results in “rebalanced hemostasis” or even may shift toward a hypercoagulable state. In addition to rebalanced coagulation there is altered platelet production due to decreased thrombopoietin production by liver, increased von Willebrand factor from low grade endothelial cell activation, and hyperfibrinolysis and dysfibrinogenemia from altered synthetic liver dysfunction. All these alterations contribute to the multifactorial nature of coagulopathy in PALF. Over exuberant use of prophylactic blood products in patients with PALF may contribute to morbidities such as fluid overload, transfusion-associated lung injury, and increased thrombosis risk. It is essential to use caution when using INR values for plasma and factor administration. In this review we will summarize the complexity of coagulation in PALF, explore “rebalanced hemostasis,” and discuss the limitations of current coagulation tests. We will also review strategies to accurately diagnose the coagulopathy of PALF and targeted therapies.

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A case of cryptogenic pseudocirrhosis causing acute liver failure: when clinic and radiology work together

Italian Journal of Medicine ◽

10.4081/itjm.2019.1129 ◽

2019 ◽

Vol 13 (2) ◽

pp. 121-123

Author(s):

Martina Finocchi ◽

Ombretta Para ◽

Giacomo Zaccagnini ◽

Lorenzo Corbo ◽

Lucia Maddaluni ◽

...

Keyword(s):

Breast Cancer ◽

Liver Failure ◽

Acute Liver Failure ◽

Systemic Chemotherapy ◽

Acute Liver Injury ◽

Metastatic Breast ◽

International Normalized Ratio ◽

Caudate Lobe ◽

Oncologic Patients ◽

Liver Changes

It is known that a wild spectrum of hepatic manifestations can be common presentations of metastatic breast cancer. Pseudocirrhosis pattern has been often described as almost always secondary to systemic chemotherapy and it is defined by morphological liver changes that mimic cirrhosis including capsular retraction, nodularity, parenchyma atrophy and caudate lobe, radiologically identifiable. Acute liver injury is an occasional complication in oncologic patients, and it outlines an organ failure when there is evidence of encephalopathy and coagulopathy (international normalized ratio >1.5) in the absence of pre-existing liver disease, with an illness of <26 weeks duration. The two most common etiologies are leukemia/lymphoma followed by breast cancer but also in this case, liver is involved almost always after chemotherapy, hormonotherapy or radiotherapy. Here we present a case of rapid evolving acute liver failure presented as cryptogenic pseudocirrhosis without any evidence of primitive breast cancer but an incidental demonstration.

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