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Cerebral blood flow, oxygen metabolism and transcranial Doppler sonography during high‐volume plasmapheresis in fulminant hepatic failure

Objective: The effect of high-volume plasmapheresis on hepatic encephalopathy, cerebral blood flow (CBF) and cerebral metabolic rate for oxygen (CMRO2) was investigated in patients with fulminant hepatic failure (FHF). Methods: Twelve consecutive patients (8 women, 4 men, median age 34 years (range 19–51)) were studied before and after high-volume plasmapheresis with 10–16 litres fresh frozen plasma, while PaCO2 and body temperature were maintained at 30 (23–34) mmHg and 37.6°C (36.6–38.4), respectively. Blood samples from the internal jugular vein and a radial artery allowed calculation of the cerebral arteriovenous oxygen difference (AVDO2) and oxygen extraction (AVDO2 divided by arterial oxygen content). CBF was determined by a xenon-133 clearance method in eight patients and CMRO2 calculated as AVDO2 times CBF. Cerebral perfusion pressure (CPP) was determined as the difference between mean arterial and subdural pressures in eight patients. Results: High-volume plasmapheresis was initiated 22 (6–168) h after the development of hepatic encephalopathy and 11 patients had grade 4 encephalopathy. Following high-volume plasmapheresis the grade of encephalopathy improved in four patients. The CBF increased from a median of 31 (16–86) to 45 (18–97) ml/100 g/min and as oxygen extraction remained unchanged (32 (9–41) vs. 29 (7–39)%), CMRO2 increased from 1.24 (0.96–1.82) to 1.86 (1.00–2.07) ml/100 g/min (P<0.05). The CPP increased from 62 (19–76) to 92 (50–105) mmHg (P<0.01), whereas the intracranial pressure remained unchanged (19 (3–45) vs. 11 (5–33) mmHg). No statistical difference was found between the relative changes in the above parameters in survivors compared to non-survivors. Conclusion: Although the clinical status did not improve in all patients, both CBF and CMRO2 increased after high-volume plasmapheresis. The alleviation of brain oxygen metabolism by high-volume plasmapheresis may reflect partial removal of neuroinhibitory plasma factors.