acute liver failure in icu

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Acute liver failure managment in Intensive care unit

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  • 1. Acute Liver failure Wahid Altaf

2. CaseThursday evening call from AnE registrar Mr C.E. 56 Year old male. Presenting complaint of Jaundice Confusion Feeling unwell Background history, liver transplant 8yrs ago with normal liver functions untill 20 days back. 3. Further questioning Hypotension Tachycardia Vasodilatory shock Severe Compensated Metabolic acidosis Ph 7.37 HCO3 14 lactate 8 Blood Glucose 2.5 Deranged Liver functions.( Bilirubin 116, ALP 357, GGT 103,AST 1241,ALT 873). 4. Definition of Liver failure The abrupt loss of hepatocellular function in a patient with previously normal liver function, the expression of which includes coagulopathy and encephalopathy. AASLDEvidence of a coagulation abnormality (INR>1.5) and mental alteration (encephalopathy) in a patient without pre-existing cirrhosis and with an illness of higher risk of cerebral edema but better prognosis for recovery Classic example: Paracetamol OD Slow onset ALF -----> lower risk of cerebral edema, higher risk of portal hypertensive problems (e.g. ascites, variceal bleeding), and ultimately poorer prognosis (w/o transplant) Classic example: NANB hepatitis 8. Etiology 9. Common drugs causing ALF Isoniazid Sulfur Antibiotics Nitrofurantoin Azole antifungals Antiepileptics- Phenytoin, sodium valproate. Herbals-ex kava kava,ma huang,comfrey. Ibuprofen Statins 10. Prognosisfamily 11. Poor prognosis Phone a friend, call Your consultant Dont hesitate to call St. Vincent University Hospital. 12. Mortality Hospital survival Mid 1970s .. 17% Mid 2000s ... 62% 13. Pathophysiology Death of a mass of hepatocytes. Loss of vital synthetic and metabolic hepatic functions. Sterile inflammatory condition leading to SIRS. Aim of management is to halt progression from hepatic impairment to MODS. 14. Investigations ALT, AST, ALP,GGT. Bilirubin, Ammonia, Lactate. Blood glucose, Coags: PT, aPTT, INR, Albumin. Electrolytes, Mg, Phos. Arterial blood gas FBC with differential. Drug screening, paracetamol levels 15. Investigations. If under 35 years of age Ceruloplasmin, Serum & urine copper Anti HAV IgM Anti HBc IgM/ Anti HBsAg Anti-HCV Pregnancy test Autoimmune markers ANA, ASMA, Ig levels HIV status Amylase & lipase 16. Invstg Diagnostic imaging Liver biopsy 17. Imaging Microbiology : Strep parasanguinus and candida. 18. Ammonia levels >75 mcg/l Encephalopathy >200 mcg/lCerebral oedema and raised ICP. 19. Cause-Specific therapy 20. Cause-specific therapy 21. N-Acetylcysetine May improve circulatory function and oxygen delivery No improvement in overall survival but significant improvement in transplant-free survival with encephalopathy grade 1-2. Time to NAC administration important Time in hrs Mortality (%) 12 6 >24 13 >48 19 Now generally recommended for all patients with ALF 22. When to pick up the phone in paracetamol overdose D2- pH 3 Cr >200 Hypoglycaemia D3- HE Cr>200 INR >4.5 D4- Any rise in INR Cr >250 HE 23. Good ICU housekeeping Stress ulcer prophylaxis No DVT prophylaxis Feeding Blood glucose management Electrolytes like phosphate and magnesium. 24. Lines Ultrasound guided No correction of coagulopathy Arterial line Central line Vascath 25. Severe Vasodilatory shock Optimise cardiac filling pressures Haemodynamics can be challenging to determine given the disruptive effects of liver failure on the vasculature Saline challenge, albumin. Vasopressors 26. Vasopressors Nor-Adrenaline Terlipressin Vasopressin..no evidence of splanchnic ischemia. 27. Sedation Avoid if possible Propofol/Remifentanyl is reasonable 28. Pulmonary considerations Airway Elective intubation Elective intubation once in grade 3 encephalopathy Rapid intubation technique Avoid spikes in ICP or decreased CPP Pneumonia Commonest site of sepsis Acute lung injury/ARDS In one third of patients 29. Renal failure Renal failure in 50% Particularly common with paracetamol overdose Liver and renal metabolites 30. Management Volume control Maintenance of blood pressure Prevention/treatment of sepsis Judicious selection of drugs Early use of renal replacement therapy Before fluid problems aggravate cardiovascular status and ICP Sodium management Better ammonia level management 31. Complications of acute liver failure and management 32. Management of complications Cerebral edema Sepsis Coagulopathy 33. Cerebral oedema 34. Predictors of cerebral edema Rapid onset ALF Rapid accumulation of glutamine overwhelms astrocytes' ability to exclude organic osmolytes Grade 3-4 encephalopathy High ammonia concentrations Infection and/or SIRS Case for prophylactic antibiotics Vasopressor therapy Renal replacement therapy 35. Invasive monitoring of ICP 36. Delaying the onset of raised ICP 37. Delaying the onset of raised ICP 38. Delaying the onset of raised ICP 39. Two principles in management of cerebral oedema 40. Raised ICP management 1st line Mannitol 2nd line Hyperventillation to PaCO2 25-35mmhg 3rd line Hypertonic saline, Hypothermia 4th line Barbiturates, Anticonvulsants Other considerations Transplantation, total hepatectomy. 41. Infection Infection is near-universal Failing liver results in failed host defences Infection precipitates MOSF, cerebral oedema Frequent cause of death Organisms Bacterial and fungal Gram negative organisms (52%) more frequent than Gram-positive organisms (44%) and Candida Infection 42. Sites of sepsis 43. Recommendations Minimize invasive procedures, strict asepsis Daily chest radiograph and surveillance cultures Empiric broad spectrum antibiotics for those patients at greatest risk: Grade 3-4 encephalopathy Renal failure Any component of SIRS Planned transplantation (includes antifungals) 44. Coagulopathy Increased INR present by definition Thrombocytopenia present in up to 70% TEG is reassuring 45. Is there bleeding diathesis? Significant bleeding is uncommon: 5% Anticoagulant proteins decrease in parallel with coagulation factors Spontaneous intracranial haemorrhage is rare Less clinically-significant bleeding may occur from several sites Gastric mucosa PPIs Invasive procedures offer the greatest risk 46. Correcting coagulopathy before invasive procedures Correction itself carries risks Volume overload Aggravation of ICP Transfusion-related acute lung injury Thromboembolism (particularly with recombinant Factor VIIa) Commonly used goal of INR 15 Severe intracranial hypertention (ICH>50) Hepatocellular criteria with Milan criteria Advanced cardiopulmonary disease.Haemodynamic unstability,requiring high dose pressors Hilar cholangiocarcinoma Uncontrolled infection Hepatopulmonary syndrome Multiorgan failure Portopulmonary hypertention Current/Recent extrahepatic malignancy unless tumour free>2yrs Primary hyperoxaluria Untrated alcoholism/Drug use Cystic fibrosis with liver involvement Severe uncontrolled mood disorders 50. Palliate Declined by liver services Refractory ICP Blown pupils Communication skills Dont forget morphine infusion. 51. In summary Causes Help Bloods NAC Early lines, dont be afraid Drugs, dialysis Raised ICP Coagulation Manage Infections Transplant Palliate