Early death from paracetamol (acetaminophen) induced fulminant hepatic failure without cerebral oedema

Background: Paracetamol overdose is a frequent cause of fulminant hepatic failure. In fatal cases the most frequent causes of death are cerebral oedema in the early phase or sepsis and multiorgan failure later. However some patients do not fit this pattern. Aim: To review cause of death in paracetamol induced fulminant hepatic failure. Methods: We reviewed all fatal cases of paracetamol induced fulminant hepatic failure in our liver unit between 1995 and 2000. Results: Twenty one patients died without liver transplantation and post mortem examinations were performed on all. Significant cerebral oedema was present in 13 patients and absent in eight. The patients without cerebral oedema were significantly older (55.4±5.3 versus 36.3±3 years: P=0.0034), had a lower arterial pH on admission (pH 7.0±0.03 versus 7.3±0.05: P=0.0008), a shorter interval between overdose and death (3.75±0.7 versus 7.6±1.3 days: P=0.043) and a shorter interval between admission and death (1.9±0.6 versus 5.7±1.0 days: P=0.0097) than patients with cerebral oedema. The cause of death in the sub-group of patients without cerebral oedema was predominantly cardiovascular collapse with rapidly progressive resistant hypotension and/or cardiac arrest. No source of sepsis was identified in 7/8 patients without cerebral oedema. Conclusions: In this series the most frequent causes of death were cerebral oedema or cardiovascular collapse. Patients without cerebral oedema appear to form a distinct subgroup associated with early mortality and may require specific management strategies.