Critical Care Refresher Course: Abdomen

Acute Liver Failure (Rothen)

Grades of hepatic encephalopathy

  • Grade 1 – Trivial lack of awareness; euphoria or anxiety; shortened attention span; impaired performance of addition or subtraction
  • Grade 2 – Lethargy or apathy; minimal disorientation for time or place; subtle personality change; inappropriate behaviour
  • Grade 3 – Somnolence to semistupor, but responsive to verbal stimuli; confusion; gross disorientation
  • Grade 4 – Coma

Acute liver failure is a multisystem disorder – hepatic damage leads to endotoxemia –> MODS

Mechanism of drug-induced hepatic damage – idiosyncratic (immune and non-immune) or toxic

Paracetamol may be used in non-paracetamol related liver injuries

Cerebral oedema occurs in up to 75% of pts with grade 4 encephalopathy

  • lactulose and rifaximine in ALF controversial

In absence of bleeding or invasive procedures in unnecessary

Prophylactic antibiotics is controversial

Prognosis is improving although it is highly dependant on the underlying aetiology

 

References

NEJM Review of acute liver failure

Aetiology of acute liver failure

Liver toxins database

Paracetamol toxicity

Management of acute liver injury

Review and King’s criteria for liver failure

 

 

Chronic Liver Diseases and Transplantation (Wendon)

Key to management is the aetiology

CT WITH contrast, US and Echo should be standard investigation in the cirrhotic patient

Organ issues

  • Cardiac – cirrhotic cardiomyopathy, impaired response to stress, diastolic dysfunction, Pulmonary hypertension
  • Renal – true hepatorenal syndrome is rare; the cause is often multifactorial. Creatinine is a very poor marker of renal impairment in liver failure. Treatment – consider terlipressin and albumin
  • CNS – encephalopathy increases ITU stay and mortality. Management – care of airway, no evidence for protein, consider precipitant and treat. MARS device has no
  • Infection
  • Varices – not all pts with varices have cirrhosis. Restrictive Hb strategy. TIPS early
  • Coagulation – pts have balanced coagulation as they also have low ATIII, protein C and S
  • Respiratory – hepatopulmonary syndrome. SHUNT!

Propofol and clonidine sedative of choice in liver failure. Small bolus opioids.

References

Lancet: Review of liver cirrhosis

Hyponatraemia and cirrhosis

Acute vs acute-on-chronic liver failure

Early use of TIPS

CANONIC Study

 

Liver Surgery (Sitzwohl)

Liver resection is increasing; metastases (majority), primary liver tumour, benign lesions

Mortality improving – 2% BUT complication 20-30%

Major complications – SEPSIS, wound infection

Fluids – less is more; CVP has direct effect on blood loss

Coagulation – abnormal lab values DO NOT predict bleeding risk = BALANCED COAGULATION. Aprotinin and transexamic acid is of uncertain value in these patients.

Sedation – NOT Midazolam. Cautious Dexmedetomidine. NOT Morphine. Bravo Remifentanil. Yes Propofol

Modified eFAST scan is useful in liver transplant patients to look for free fluid

 

References

Morbidity and mortality after liver surgery

CVP and liver resection

Renal failure after liver transplants

Probiotics in liver transplant