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Objective: To describe the experience with a multimodal therapeutic approach in a patient who developed toxic liver syndrome and fulminant hepatic failure following orthotopic liver transplantation (OLT) as a result of occlusion of the portal vein. Setting: Department of Intensive Care. Patient: A patient with liver cirrhosis secondary to autoimmune hepatitis and primary biliary cirrhosis who underwent orthotopic liver transplantation (OLT). Interventions: Transplant hepatectomy, plasmapheresis and retransplantation. Case Report: A 39-year-old man underwent an elective OLT. A routine postoperative doppler ultrasound examination a few hours after surgery revealed portal vein thrombosis. Attempts at recanalization failed, and the patient developed acute fulminant liver failure, which remained resistant to supportive therapy. A transplant hepatectomy was performed 9 hours later and plasmapheresis started. Following a 10-hour anhepatic period, the patient received a second liver, from an ABO-incompatible donor. The patient underwent column plasmapheresis and subsequent splenectomy to remove anti-B antibody to preserve the incompatible transplanted liver from immunogenic complications. The patient spent a total of 21 days in the Intensive Care Unit (ICU) before being discharged to a step-down ward. Conclusion: Our experience suggests that multimodal therapy, including transplant hepatectomy, plasmapheresis and retransplantation of an even non-ABO compatible liver may result in the successful outcome in patients with acute fulminant liver failure complicating OLT.

Background: Long-term inadequate dietary consumption may increase the possibility of malnutrition, morbidity and mortality. Enteral nutrition (EN) is a beneficial support that could help to maintain nutritional status and gut function. Aim: Our aim was to evaluate the effect of moderately high-protein enteral formula containing fibre on nutritional status, and its safety. Method: A total of 23 tube-feeding-dependent adult patients were included in this multicentre, open-label study. The patients were fed with the study formula for 7–12 days or equal to the required nutritional support period, during which we performed physical examinations and assessed nutritional status. The primary endpoint was the statistical difference in nutritional status after the treatment, and the secondary outcome was the desirable safety profile. Results: A significant improvement in cumulative energy balance after intervention was observed ( p = 0.008). However, the differences in nutritional status, weight and BMI before and after the intervention do not reach statistical significance. Retinol-binding protein (RBP), a marker for nutritional status, increased from baseline levels. Few cases of diarrhoea and constipation had been reported during the study as a safety concern. Conclusions: This study investigated the efficacy and safety of an enteral feed formulation containing fibre. The patients were nourished with the studied formulation via tube feeding for a short period without serious adverse events. After the intervention, the significant increase in cumulative energy balance was observed. However, an extended period of the intervention may be required to attain the significance in other indicators for nutritional status.

The benefits of early enteral nutrition (EN) support have been well established in critically ill patients. Early nutrition intervention, commencing within 24 hours of admission, has been associated with a decrease in mortality and infection complications compared to more delayed standard care nutrition support (1,2).

Treating respiratory distress is a priority when managing critically ill patients. Non-invasive ventilation (NIV) is increasingly used as a tool to prevent endotracheal intubation. Providing oral or enteral nutritional support during NIV may be perceived as unsafe because of the possible risk of aspiration so that these patients are frequently denied adequate caloric and protein intake. Newly available therapies, such as high-flow nasal oxygen (HFNO) may allow for more appropriate oral feeding.