I have no financial relationship(s) to disclose relevant to my presentation.

julia.wendon@kcl.ac.uk

All Fluids are bad The Liver and abdominal hypertension

Julia WendonConsultant Intensivist and Hepatologist

Institute of Liver Studies Kings College Hospital

London

A bit is good – too much – well

Potential Categorization of liver dysfunction in critical care /MOF

Primary liver InjuryAcute

Acute liver Injury

Acute Liver failure

Chronic

Decompensated CLD

Critically ill cirrhotics

Surgical

Hepatectomy

Trauma

Iatrogenic

Secondary liver Injury Sepsis / inflammation

Ischemia/Congestion

Systemic disease

DrugsTPNOther…..

Fluids and liver disease

• 5% dextrose • 20-50% dextrose • N/ Saline / Hartmans / balanced crystalloids

• Colloids • 4.5% albumin 20% albumin • gelatins , starch

Haemodynamics and issues • ALF

– Initially all volume deplete – difficult to say fluid is bad

– Risk of pancreatitis, gut oedema – Stiff liver, develop ascites easily

• Hepatic resection – Initially usually run dry – Risk of small for size syndrome – Portal inflow excessive to outflow– Adequate but not excess fluid required

Haemodynamics of cirrhosis • Group 1

– Ascites, central hyovolaemia, total blood volume increased, usually diuresed ++ and low na and poor kidneys

• Group 2– RV volume / pressure overload, ascites and oedema,

cirrhotic cardiomyopathy, No PHT, usually high CI TPG• Group 3

– Portopulmonary syndrome with normal RA, initially maintained CI

Situations for discussion • Acute liver failure

– Plasma exchange

• Ascites and drainage of said • Variceal haemorrhage • Hepatorenal failure

• Continuity between right heart, hepatic veins, liver and sinusoids and back to portal vein and hence guts – gut oedema, translocation

IAP

CVPPcwP

PeeP

Compliance ↓

Echo findings also predictive of mortality post TIPS

IAP and fluid responsiveness

Problems related to hypotonic solutions

Replace with albumin 20% to prevent PICDAlso consider risk of variceal bleeding

Consider IAP and renal perfusion pressure Options 1. Decrease IAP 2. Increase RPP 3. Improve central blood volume

RPP 61 to 67 mmHg

Potential risk of variceal bleed ???

Pre paracentesis4-10 L +ive Pressors 0.45 µg/kg/min9 L ascitesDrained

Replaced 20% Albumin 1.2 L

PLR : no increase

Terlipressin ± albumin Ortega et al Hepatology 2002;36:941

0.5 mg 4 hrly , albumin 1g/kg/body weight day 1 then 20 - 40 g/day

Sanyal A Gatroenterology 2008 :134:1360

Albumin daily 1g/kg

Martin-Llahi M Gastroenterology 2008:134

Data also for norepinephrine and Ptx and NAC

10 trials only type I and II Drug ± alb vs no intervention

Vasoconstrictors + Alb : Effect on mortality at 15 days but not at 30, 90 or 180 days RR 0.6 (0.37-0.97)

Terlipressin + Albumin vs Albumin : decreased mortality in type IRR 0.83 (0.65-1.05)

MAP no relationship to changes in GFRMAP increased (>85)Reversal of RAA, NE levels

Creatinine is Dreadful measure Of renal function

Airway Breathing Circulation

fluids - coagulation factors ??

others ?Na issues IAP – ascites &

endoscopyTerlipressin / somatostatin

Watch right sided pressures

• 116 patients with cirrhosis and variceal bleed• Endoscopy and sclerotherapy• HVPG measured within first 24 hours: < or > 20

mmHg• If > 20 randomized to TIPS or medical Rx

Monescillo Hepatology 2004 ;40:793

Rx failureHVPG and CPscore

6 week survival

alb

Given over 6 hours for 20% albumin and 18 hrs for HES 6%1.5 g/kg at day 1 and 1.0 g/kg at day 3

1235 patients screened : 101 RV > 50 mmHgMPAP > 25 mmHg in 90%

PPS observed in 55%Remainder relate to increased MPAP in response to increased flowsCalculate transpulmonary gradient (MPAP-PAOP)

Poor correlation with MELD

IAP 11.8±3.6

PDR 26.6 ± 13 vs 21.8± 7.8 (NS)

CVP 9.3±4.6 vs 15.7±4.7 (p<0.001)

Individual variation was however observed

• SBP frequently associated with renal failure• Associated with decreased effective blood volume

and high mortality• 126 patients iv cefotaxime or iv cefotaxime plus

albumin (1.5g/kg) at day 0 and day 3 (1.0 g/kg)• 94% and 98 % had resolution of infection• Renal failure in 21 (33%) cef grp vs 6 (10%) in alb/cef

grp p=0.002• Mortality 18 (29%) vs 6 (10%) • At 3 months the mortality was 41% vs 22% p=0.03

Albumin and renal impairment in patients with cirrhosis and SBP Sort P et al N Engl J Med 1999 5; 341 (6):403

cirrhosis

Budd chiari