thiopental and Hepatic-Encephalopathy

A 48-year-old man with end-stage liver disease and aortic stenosis (AS), was being evaluated for liver transplantation. This report focuses on the question of which medical problem to correct first, the end-stage liver disease or the AS. Risk factors for surgical correction of AS and liver transplantation are reviewed and discussed, and the surgical and anesthetic management strategies for this patient are outlined.

Topics: Anesthesia, General; Anesthetics, Inhalation; Anesthetics, Intravenous; Aortic Valve Stenosis; Blood Pressure; Cardiac Output; Fentanyl; Heart Rate; Hepatic Encephalopathy; Humans; Isoflurane; Liver Transplantation; Male; Middle Aged; Neuromuscular Depolarizing Agents; Patient Care Planning; Risk Factors; Succinylcholine; Thiopental; Ventricular Function, Left

Topics: Acetaminophen; Adult; Analgesics, Non-Narcotic; Brain Death; Brain Edema; Female; Hepatic Encephalopathy; Humans; Hypnotics and Sedatives; Intracranial Pressure; Liver Transplantation; Propofol; Thiopental

Intracranial hypertension complicating fulminant hepatic failure has a mortality in excess of 90% in the presence of renal failure if not rapidly responsive to mannitol and ultrafiltration. Based on data which suggest that barbiturates can be of value in controlling the intracranial hypertension of head injury, intravenous thiopental was assessed in 13 patients with fulminant hepatic failure. All had developed acute renal failure complicated by intracranial hypertension unresponsive to other modes of therapy and were likely by all published criteria to have little chance of survival. The dosage of thiopental was adjusted incrementally until intracranial pressure, measured by extradural transducers, fell to within normal limits or adverse hemodynamic changes occurred. The intracranial pressure was reduced, in each case, by 185 to 500 mg (median: 250 mg) thiopental given over 15 min, and in eight cases continuing infusion achieved stable normal intracranial pressure and cerebral perfusion pressure. Five of the patients made a complete recovery and there were only three deaths from intracranial hypertension. Side effects were few and included minor hypotension controlled by dose reduction. The response of otherwise intractable intracranial hypertension and the 38% survival rate was remarkable for a group of patients with such a poor prognosis.

Topics: Adult; Female; Hepatic Encephalopathy; Humans; Hypotension; Infusions, Intravenous; Intracranial Pressure; Male; Middle Aged; Pseudotumor Cerebri; Thiopental

The effects of certain drugs on metabolism of ammonia by the liver and kidneys in dogs were investigated by a technique in which both hepatic inflow and outflow bloods could be repeatedly sampled in unanesthetized healthy animals. Specific representatives of the classes of the drugs studied included thiopental (barbiturates), morphine (opiates and analgesics), promazine (tranquillizers), and chlorothiazide (oral diuretics).The three drugs commonly used as sedatives were all found to impair the ability of the liver to metabolize ammonia. The diuretic, by contrast, increased the amount of ammonia put into the systemic system by the kidneys. Ethanol appeared to have little or no direct effect on ammonia metabolism.The possibility exists that the occurrence of acute hepatic encephalopathy in patients with severe liver disease may be avoided in many cases if these drugs are administered with proper care. Results also indicated that current concepts of the pharmacological action of sedatives, opiates and tranquillizers may require revision.

Topics: Amines; Ammonia; Animals; Blood Chemical Analysis; Brain Diseases; Chlorothiazide; Diuretics; Dogs; Ethanol; Hepatic Encephalopathy; Kidney; Liver; Liver Diseases; Metabolism; Morphine; Neurologic Manifestations; Promazine; Thiopental; Toxicology