OVERVIEW
- may come to ICU for many reasons:
(1) encephalopathy from acute decompensation
(2) sepsis
(3) renal failure
(4) variceal bleeding
(5) cardiorespiratory failure
ENCEPHALOPATHY FROM ACUTE DECOMPENSATION
Find cause:
- sepsis
- spontaneous bacterial peritonitis
- GI haemorrhage
- alcohol
- drugs (opiates, sedatives, diuretics)
- electrolyte imbalances
- hepatocellular carcinoma
- portal vein thrombosis
- dehydration
HISTORY
- weakness & fatigue
- jaundice
- abdominal pain or swelling
- altered mental state
- pruritis
- durations of disease
- alcohol intake
- IV drug use
- blood transfusions
- tattoos
- overseas travel
- drugs (isoniazid)
EXAMINATION
- general – abdominal distension, jaundice, cachexia, bruises
- palmar erythema
- bruising
- spider naevi
- yellow sclerae
- fetor
- gynaecomastia
- abdomen: masses, distension, bruising, scars
- hepatosplenomegaly
- ascites
- bruits
INVESTIGATIONS
- FBC – anaemia
- U+E – hepatorenal syndrome
- BSL
- LFTs – active damage
- Albumin – synthetic function
- Coag – bleeding
- ABG – lactate acidaemia
- alpha-feto protein
- paracentesis: culture and cell count (>250/mm3 = diagnostic for SBP)
- endoscopy – varices
- US: hepatic and portal veins, hepatocellular carcinoma
- CT: hepatocellular carcinoma
- liver biopsy
MANAGEMENT
- resuscitate: intubation to protect airway
- albumin IV
- lactulose to decrease ammonia levels
- monitor glucose
- vitamin K and FFP for coagulopathy
- MARS therapy
- feed enterally and can use protein
- find cause and treat:
-> antibiotics in SBP: third generation cephalosporin or tazocin + spironolactone
-> steroids in alcoholic hepatitis
-> consider for transplantation
SURGICAL RISK – Child-Pugh Classification (see liver failure definitions)
A | B | C | |
Mortality | < 5% | 5-50% | 50% |
Bilirubin (mmol/L) | <25 | 25-40 | 40 |
Albumin (g/L) | >35 | 30-35 | <30 |
Ascites | none | moderate | marked |
Nutrition | excellent | good | poor |
INR | <1.7 | 1.7-2.3 | >2.3 |
Encephalopathy | grade 0 | grade 1-2 | grade 3-4 |
COMPLICATIONS
Sepsis
- immunosuppressed
- SBP: gram negative rods, strep pneumoniae, enterococci
- other organisms: Listeria, Tb, Fungi, CMV, norcardia
-> early source control
-> early antibiotics (empiric)
Renal Failure
- hepatorenal syndrome -> more likely to see rapidly progressive form
- also consider abdominal compartment syndrome
- investigation: U/S: renal and hepatic
-> volume expansion with colloid (albumin)
-> vasoconstriction (noradrenaline or glypressin)
-> ascitic drainage with albumin loading
-> consider TIPs procedure in Budd-Chiari syndrome
-> consider transplantation
Variceal Haemorrhage
- decreased production of factors, thrombocytopaenia, platelet dysfunction)
-> resuscitate
-> correct coagulopathy
-> sepsis of precipitant: culture and give antibiotics
-> splanchnic vasoconstriction: glypressin
-> endoscopy: banding and ligation
-> TIPS procedure
-> transplantation
Encephalopathy
- causes: sedation, high protein diet, infection, trauma, hypokalaemia, constipation -> accumulation of toxic products
- grade 0 = alert and orientated, grade IV = unresponsive to deep pain
Others
- hypoglycaemia (decreased glycogen stores)
- ascites (from portal hypertension and fluid retention)
- cholecystitis
- pancreatitis
Critical Care
Compendium
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