Hyperbaric oxygenation, plasma exchange, and hemodialysis for treatment of acute liver failure in a 3-year-old child

A girl aged 3 years and 4 months weighing 16 kg was treated with plasma exchange (PE), hemodialysis (HD), and hyperbaric oxygenation (HBO) for acute hepatic failure and coma. She was given a total of 13 PEs, 13 HD sessions, and 9 HBO treatments over a period of 1 month. The initial 4 PEs were followed by HD sessions while the other 8 PE treatments were given simultaneously with HD. There was no renal failure; HD was instituted to improve ammonia elimination. In 1 HD session, 20% human albumin (370 ml) was used as the dialysate to enhance bilirubin elimination. Three volumes of plasma (2,000 ml) per PE were exchanged and replaced with fresh frozen plasma (FFP). The Bellco BL 791 plasmapheresis monitor and Gambro PF1000 and PF2000 plasma filters were used. Heparin was added to prevent clotting. A dual lumen pediatric HD catheter (7 Fr) placed percutaneously into the femoral vein was used as a blood access. The Fresenius 2008 C HD monitor and the Filtral 10 dialyzer were used for HD. PE and HD were instituted simultaneously to prevent the tetanic (hypocalcemic) cramps observed with 2 previous PEs due to citrate in the FFP. The extracorporeal circuit was primed with a mixture of concentrated red cells, human albumin, and saline solution and was discarded at the end of the procedure. The average blood flow rate in PE and/or HD circuits was 80 ml/min. During HBO, the girl breathed 100% oxygen at 2.5 atm for 90 min. Throughout the treatment, the patient was in good clinical, physical, and mental condition, but she was dependent on blood purification procedures. She was referred to a liver transplant center and successfully transplanted. The etiology of liver failure has not been clarified.