Difficult extubation following recovery from acute liver failure: Use of point-of-care critical care assessment

Excerpt

Acute liver failure (ALF) is associated with high mortality in the absence of good critical care or access to timely transplantation. The most common cause for ALF globally is acetaminophen toxicity; however, in India, the most common cause is acute viral hepatitis [1]. The causes for mortality in such patients are raised intra-cranial pressure (ICP) or complications such as secondary organ failures or sepsis. Modalities to lower raised ICP include the use of hypertonic saline or mannitol, with airway protection by mechanical ventilation (MV) in patients with worsening hepatic encephalopathy (HE) and sedation to prevent ICP fluctuations and allow for a controlled PaCO2 range [2]. Once liver-related dynamic scores improve, patients are weaned from MV weighing the risk of early extubation in the setting of cerebral edema and the effects of delayed extubation such as ventilator and ICU-associated infections, either of which situations increase mortality [3]. Herein, we discuss two interesting cases, where decisions to extubate were based on the role of specialized liver intensive care units (ICU) in managing patients with ALF [4]. …