“Bridge Therapy” could be defined aMaximal Supportive Intensive Care plusB.A.L.Despite improved surgical techniquesUNOS 2002 data reports(11%)patientswith A.L.F. died while waiting for OLTx.Our experience in bridging therapy ofA.L.F.patient to suitable liver transplantis based on both branches such of a Strategy:MSIC and Bioartificial liver device(AMC — BAL). The first phase of our protocolis MSIC treatment in ICU, in quietenvironment, head elevated 10Â° receivingas a little sedation as possible, with theavoidance of benzodiazepines.Foley catheter, triple lumen I.V. cath,arterial line (mean arterial pressure, andammonia, lactates, blood gas samples),ECG monitoring, O2 saturation, ParentalNutrition (if HE grade 3 — 4 ) omeprazole,NAC (as soon as possible in case ofparacetamol), assisted ventilation previatracheal intubation, partial boweldecontamination. Surveillance of fluidsbalance and electrolytes (risk of brainoedema), hemodynamics (norepinephrine,dopamine, fenoldopam), renal functionCRRT, blood gas, lactate, ammonia.Coagulation (fresh frozen plasma andclotting factors only at manifest bleeding).Blood sugar (every 6 hrs), caloric intake:50 —60 gr protein per day, 2000K cal Liver enzymes tests and bioumoralroutine tests.In our experimental observation in AMCBAL in the treatment of liver ischemicanhepatic pig the BAL with porcinehepatocyte in the extracorporealcirculation seems to work like an earlyliver graft doing the unique necessarybiological operation that only theHepatocyte can do,id est: lactate consuptionpromoving bicarbonate productionsustaining acido-basic, termoregulation,autonomic nervous system functioning withthe normal relationships among the organsand systemic haemodinamics.Conclusions:In this study, patient with grade III and IVcoma, waiting for OLTx have beensuccessfully bridged to transplantation orliver regeneration during a waiting periodof several days.Bilirubin and ammonia plasma concentrationdecreased more in comparison toother publishedBAL systems results. There are at leastpositive findings related to a so largemass of vital fresh-isolated hepatocytescharged in and to the particular design ofthe bioreactor that allows almost everyhepatocyte to enter in direct contact withthe patient plasma.We believe that settingsuch of a viable biological liver supportingdevice is at date the most appropriateapproach in a multimodal Strategy of ALFbridging the patient safe to OLTx or to aspontaneous recovery.
E. Di Florio
Dirigente di II livello: Responsabile di Struttura Complessa di Anestesia e Rianimazione AORN A.CARDARELLI, Napoli