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
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
Acute vs acute-on-chronic liver failure
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
Renal failure after liver transplants
Probiotics in liver transplant