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4 What Can We Do to Treat PLF
Postsurgical Liver Failure
avoidance of water overload. Coagulopathy may occur after major liver resection.
In the absence of bleeding, usually it is not necessary to correct clotting abnormalities except for invasive procedures or when coagulopathy is severe. Vitamin K may
be given but there is no support by clinical trials. Thrombocytopenia may complicate liver failure. Indications for platelet transfusion in acute liver failure include
bleeding, severe (<20 × 106/L) thrombocytopenia, or when an invasive procedure is
planned. A platelet count >70 × 106/L is deemed safe for interventional procedures.
Nutrition is important and supplementation should be established early in patients
with liver failure. Enteral nutrition is the preferred route as it improves gut function
and restores normal intestinal flora. Cerebral edema and intracranial hypertension
may occur as a result of PLF. Cerebral edema is unlikely in patients with grade 1 or
2 encephalopathy. With progression to grade 3 encephalopathy, a head CT should be
performed to exclude intracranial hemorrhage or other causes of declining mental
status [13, 19, 27].
Extrahepatic assistance devices have been developed in the last years. They fall
into two categories: artificial and bioartificial systems. Artificial devices use combinations of hemodialysis and adsorption over charcoal or albumin to detoxify plasma.
Bioartificial devices use human or xenogeneic hepatocytes maintained within a bioreactor to detoxify and provide synthetic function.
These systems have not been evaluated extensively in patients with PLF. Outcomes
for the use of these different devices in the management of acute liver failure are
also unclear . Therefore, currently, their role in PLF is undefined.
Liver transplantation is the only radical treatment in patients with end-stage
liver disease. However, patients with PLF are rarely eligible for it because of tumor
or the severity of their comorbid conditions. Moreover, liver transplantation for
PLF is associated with significant morbidity. Therefore, the use of a rescue hepatectomy and subsequent liver transplantation in patients suffering from PLF may
be of value in desperate situations where conventional measures fail. It is based on
the concept that the “necrotic liver” is the source of unknown humoral substances
that contribute to the systemic inflammatory response syndrome . The use of
salvage hepatectomy and orthotopic liver transplantation for PLF has been reported
in a case series of seven patients who underwent liver resection for cancer with an
overall 1-year (88 %) and 5-year (40 %) survival promising rates . However, it
has been suggested to limit liver transplantation to patients below the age of 70
years, with HCC and no macrovascular invasion, and, possibly, a small cholangiocarcinoma (less than 3 cm) without lymph node invasion. There is no indication for
transplantation in patients with liver metastasis, except those with neuroendocrine
PLF is a serious and life-threatening complication in patients undergoing major
liver resections or limited functional reserve due to preexisting liver disease.
Adequate preoperative risk assessment of liver function and general condition,
parenchyma-sparing surgery, and optimal intra- and postoperative management and treatment are essential for preventing PLF. Early diagnosis of this
complication can help initiate early treatment in the ICU aiming at optimizing
and recovering both hepatic and extrahepatic organ function. Extracorporeal
liver devices are still experimental in this particular clinical setting. The anesthetists, in their quality of leaders of the perioperative process of patients
undergoing complicated surgery, play a key role in the management of this
class of patients and are called to address the knowledge gap that still characterizes this particular clinical setting.
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What Is Delirium?
Delirium or acute confusional state is a syndrome characterized by the depression
of the highest mental functions and by a typical time course [2, 17]. Symptoms
occur acutely, manifest a fluctuating trend, especially in relation to night and day
alternation, and in most cases resolve without leaving sequelae. Condition for diagnosis is that such symptoms cannot be explained with a state of preexisting dementia, in accordance with the definition given by the Diagnostic and Statistical Manual
of Mental Disorders (DMS-IV): “The essential feature of a delirium is a disturbance
in consciousness that is accompanied by a change in cognition that cannot be better
accounted for by a pre-existing or evolving dementia.”
Alterations of consciousness do not reach the severity of stupor or coma; rather,
patients do not pay attention to the surrounding environment and in certain phases
may have a more or less marked drowsiness. The attention span is reduced, and they
are easily distracted during the interaction with doctors and family members.
Among cognitive processes, memory of recent events and orientation in space and
time are particularly compromised. Often, patients do not know where they are (in
the hospital, in the orthopedic ward, etc.) nor have the correct time references
(which day and time are now, it is day or night, how old they are, etc.). There may
also be language disorders, such as an inability to speak or write object names.
Disorders of emotions manifest themselves from time to time with anxiety, fear,
depression, irritability, anger, or euphoria. Diagnosis is often suspected when the
patient reports altered perceptions, spontaneously or at the request of the doctor.
Altered perceptions are classified into misinterpretations, delusions, and hallucinations. An example of misinterpretation of a real situation is to believe that the
Department of Cardiovascular Sciences, Catholic University of the Sacred Heart,
Largo Francesco Vito 1, Rome 00168, Italy
© Springer International Publishing Switzerland 2016
D. Chiumello (ed.), Topical Issues in Anesthesia and Intensive Care,
administration of a drug is an attempt to poison or that hospitalization is a kidnapping. An illusion is an erroneous perception of a sensation, often visual; for example, an infusion line or a fold of the sheet may look like a snake or a worm. A
hallucination is a perception that does not match any real sense; particularly frequent is watching insects on the walls or persons in the vicinity of the bed.
Psychomotor activity is also affected by delirium. There are two distinct forms,
the overactive one, characterized by hyperactivity, restlessness, and insomnia, and
the underactive one, characterized by hypoactivity, drowsiness, and detachment
from the environment. Mixed forms are also possible, alternating hypo- and hyperactive phases. Hyperactive forms are often easier to diagnose because patient management becomes problematic. Delirium is classified as prevalent when it is already
present at the admission to the hospital, incident when it occurs during hospital stay,
and subsyndromic when it does not match all the criteria needed for diagnosis .
Finally, delirium may overlap to a preexisting dementia .
Incidence of Delirium in the Perioperative Period
Postoperative delirium typically occurs in the first 48 h after surgery. It must be
distinguished from the transient phenomena of agitation that may be observed during recovery from anesthesia and from postoperative cognitive dysfunction which,
likewise delirium, affects superior brain functions, first of all the memory, but has
different characteristics (Table 10.1).
Incidence of delirium varies in different series, but is anyway high, especially in
the elderly. After elective surgery, delirium affects between 10 and 75 % of patients
older than 65 years . This percentage is heavily influenced by the type of surgery.
For example, delirium occurs more frequently after vascular surgery and oral surgery of long duration (36 and 42 %, respectively) than after ophthalmologic procedures, such as extraction of the lens (4.4 %). Hip surgery is also characterized by a
high incidence of postoperative delirium (5–30 %), which increases if the intervention is associated with prolonged bed rest as in traumatic fractures.
Influence of surgery can be explained in part by the characteristics of interventions (duration, amount of postoperative pain, risk of hypotension, hypoxia, and
anemia) and in part by patient features. For example, vascular surgery is often
Table 10.1 Differential
diagnosis between delirium
and postoperative cognitive
Sometimes after months
Modified from Krenk and Rasmussen 
performed on elderly patients, affected by arterial hypertension and suffering from
an advanced degree of atherosclerosis. Of note, the incidence of postoperative delirium is positively correlated with the number of hypotensive episodes, of arterial
desaturations, and of blood transfusions that occur during the surgical procedure.
Etiology and Pathogenesis
The etiology of postoperative delirium is complex and multifactorial. Causes and
contributing factors can be divided in five groups:
(a) Factors that alter brain metabolism. These include hypoperfusion, hypoxia,
anemia, hyperthermia, fluid and electrolyte abnormalities, liver and kidney failure, some endocrine disorders, and deficiency of vitamin B1 and B12.
(b) Abnormal and annoying stimuli and, in general, all that can alter perceptions.
Pain caused by inadequate analgesia facilitates the onset of delirium (although
opioid administration can be a facilitating factor). This is particularly relevant
for the elderly or for patients suffering from dementia who are very susceptible
to the onset of delirium and often receive inadequate doses of analgesics.
Endogenous stimuli, e.g., relating to constipation or bladder distension, may
also induce the occurrence of delirium. Finally, inadequate ambient lighting or
removal of hearing aids or glasses may alter patient perceptions, favoring the
isolation of the patient himself and the appearance of altered perceptions.
(c) Some drugs, often having anticholinergic activity. They include some analgesics (codeine, meperidine, morphine), antibiotics, antifungals and antivirals
(acyclovir, amphotericin B, cephalosporins, ciprofloxacin, imipenem-cilastatin,
trimethoprimsulfamethoxazole), antiepileptic drugs (phenobarbital, phenytoin), cardioactive
drugs (captopril, clonidine, digoxin, dopamine, labetalol, lidocaine, nifedipine,
nitroprusside, procainamide, propanolol), drugs of abuse (alcohol, sedatives,
hypnotics, hallucinogens, amphetamine, cannabis, cocaine, phencyclidine), and
others (hydroxyzine, ketamine, metoclopramide, theophylline, atropine, scopolamine, nonsteroidal anti-inflammatory agents).
(d) Acute suspension of certain drugs and substances that are active on the nervous
system, such as sedatives, opioids, alcohol, and nicotine.
(e) Environmental factors. Sometimes, delirium occurrence is simply caused by
partying from home and relatives, admission to the hospital, and prolonged bedding. In intensive care units, environmental noise and night lighting worsen the
quality of sleep and alter circadian rhythm. Absence of time references, such as
calendars and clocks, and the lack of information and entertainment tools, such
as books, newspapers, radio, and television, favor patient disorientation in time
and space and, ultimately, cause delirium occurrence.
The pathogenesis of delirium is also complex and still not fully cleared. It
has been hypothesized that a role is played by an imbalance in the brain