Exchange transfusion and major surgery in acute hepatic failure

Of the many techniques available for short-term support of the failing liver, a closed "isovolemic" method of exchange transfusions remains simple and safe. We used this method to exchange 143 U. of blood in eight patients in Stage III/IV hepatic failure; four patients had no previous underlying liver disease. Significant improvements of biochemical and coagulation parameters resulted. Serum bilirubin, glutamic oxaloacetic transaminase and, lactic dehydrogenase levels fell from a mean, 24.7 mg. per 100 ml., 3,100 mU. per milliliter, 2,796 mU. per millilter, respectively, to 10.9 mg. per 100 ml., 122.9 mU. per milliliter, and 558.5 mU. per milliliter, respectively, 6 to 12 hours following transfusion. Prolongation of serum prothrombin and thrombin times (over controls) of 31.1 and 30.1 seconds (mean) were markedly decreased to 3.2 and 6.1 seconds 6 to 12 hours following transfusion; partial thromboplastin times were decreased from a mean 196.4 seconds to 87.8 seconds after the same period. Levels of Factors VII, IX, and X were increased transiently. Correlations of exchange transfusion to reversal of coma and improvements in electroencephalograms were poor. Two patients in coma were subjected to major surgery following exchange transfusion; one patient survived vagotomy and hemigastrectomy for stress bleeding and one withstood a temporary baboon liver heterotopic transplant which aided in recovery from coma. We recommend isovolemic exchange transfusion as specific treatment for coagulation abnormalities and as an over-all aid in lowering the mortality rate of patients in hepatic coma. Marked improvements in homeostasis make major surgery feasible.