Acetaminophen Toxicity: When to Consult the Transplant Surgeon

Giacoppe GN, Degler DA Rapidly evolving adult respiratory distress syndrome with eosinophilia of unknown causse in previously healthy active duty soldiers at an Army training center: report of hvo cases hfil hfed. determined rapidly given the amount of time and effort needed to secure a suitable matched donor In those selected for transplant, 40 to 50% will die while awaiting a suitable donor ' Before OL-I the overall survival rate for patients with fulminant hepatic failure from all causes was less than 20%.' With the use of OLT, patient survival rates are approximately 54-74% and are improving'" Fulminant hepatic failure (FHF) is defined as acute liver disease occurring in the absence of pre-existing liver disease, leading to encephalopathy within 8 weeks of symptom onset or within 2 weeks of onset of jaundice Acetaminophen is the most common drug to cause FHF in the United States and in Great Britain The overall moitality rate from acetaminophen toxicity (including patients without encephalopathy) is 20%.' Given the benefit of OLT in the setting of FHF, it is essential that ED physicians obtain early consultation with liver uansplant specialists in cases where certain prognostic indicators are met',' FHF from acetaminophen toxicity presents with a variety of clinical manifestations Nausea and vomiting predominate early and typically diminish in severity over 24 to 48 hours. Hepatic necrosis with an increase in serum transaminases (AST, ALT), bilirubin and prothrombin time 1 ensues; complaints of righi upper quad& abdominal pain TOPICS lN TOXICOLOGY are common Dehydration, renal insufficiency and oliguria may also occur during this time period Between 2 to 5 Acetaminophen Toxicity: When t o Consult t h e T r a n s p l a n t Surgeon Acetaminophen overdose remains a leading cause of druginduced toxicity presenting to the Emergency Depariment The diagnosis and manage. ment of acute acetaminophen ingestions are largely based on patient history and serum drug levels obtained in the ED While ED physicians should be well versed regarding the management of such cases, it is the patient with a delayed presentation who already exhibits siens and symptoms of hepatic toxicity hat is-.. more challenging. Clearly, any patient already manifesting acetaminoohen-induced herratotoxicity-should be admitted and receive N-acetylcysteine But when will they need a liver hansplant? What are the prognostic indicators of poor outcome in these patients? When should we call the transplant surgeon and arrange early transfer to a hospital with …