ABSTRACT
OBJECTIVE: To assess the safety and efficacy of a protocol to support management of intracerebral pressure in patients with fulminant liver failure (FLF). DESIGN AND SETTING: A prospective series was conducted between May 2004 and September 2006 at Banner Good Samaritan Medical Center, a 650-bed teaching hospital in Phoenix, Arizona. PATIENTS: We recruited consecutive patients with FLF and stage 3 or 4 encephalopathy. INTERVENTIONS: We placed an intracranial pressure monitor in each patient and employed a protocol to support decisions regarding hemostatic management and prevention and treatment of intracranial hypertension (IHTN). Treatment modalities included hypothermia, hypocarbia, intravenous pentobarbital, intravenous mannitol and vasopressor titration for maintenance of cerebral perfusion pressure. The main outcome measure was survival in transplant candidates. MEASUREMENTS AND MAIN RESULTS: Twenty-two patients entered the study and 21 (95%) had at least one episode of IHTN. Eighty-two discrete episodes of IHTN occurred, and 78 of these (95%) resolved with treatment. Overall survival was 55%. Eleven of 18 (61%) of transplant candidates survived with good neurologic outcome. No patient died from isolated cerebral edema. Three patients had intracranial hemorrhages related to the intracranial pressure monitor. CONCLUSIONS: Protocol-driven management of intracranial pressure in FLF can result in good clinical outcomes in most transplant candidates, even if IHTN occurs.
Subject(s)
Hypnotics and Sedatives/therapeutic use , Intracranial Hypertension/etiology , Intracranial Hypertension/therapy , Liver Failure, Acute/complications , Pentobarbital/therapeutic use , Adolescent , Adult , Brain Edema/etiology , Female , Hemostatics/therapeutic use , Hospital Mortality , Humans , Hypothermia, Induced , Intracranial Hypertension/prevention & control , Intracranial Pressure , Liver Failure, Acute/classification , Liver Failure, Acute/therapy , Logistic Models , Male , Middle Aged , Monitoring, Physiologic/methods , Severity of Illness IndexABSTRACT
Coccidioides immitis is a fungus endemic to the southwestern United States. Susceptible hosts, including blacks, Hispanics, Filipinos, Native Americans, and those with compromised immunity, may develop disseminated disease, including fungemia. We retrospectively reviewed the records of all patients (n = 33) with Coccidioides immitis fungemia (CIF) at a 550-bed public hospital in Phoenix, Arizona, from 1990 to 2002. This is the largest reported series of CIF. The purpose of the study was to review the incidence, signs, symptoms, and outcomes of CIF. Twenty-nine patients had human immunodeficiency virus infection. CIF was associated with sepsis, end-stage alcoholic liver disease, and diabetes in four patients. Survival was poor; 24 of the 33 patients died within 28 days. CIF manifested as a systemic inflammatory response syndrome with progressive cardiorespiratory failure. Despite fluid loading, infusion of vasoactive agents, and mechanical ventilation with positive end-expiratory pressure, patients typically experienced a rapidly progressive course and death. CIF portends an ominous prognosis and typically occurs in the setting of advanced human immunodeficiency virus or medical or surgical crises.
