CICM SAQ 2012.2 Q11
A 42-year-old male is admitted to ICU following a cadaveric orthotopic liver transplant for end-stage liver disease secondary to alcohol-induced cirrhosis.
- a) List the important management principles for the first 24 hours specific to this patient.
- b) Despite weaning sedation he remains unresponsive 12 hours after ICU admission. What are the possible causes?
Answer and interpretation
a) List the important management principles for the first 24 hours specific to this patient.
- Haemodynamic stabilization – optimize cardiac output and tissue perfusion and avoid fluid overload as ventricular function may be impaired. Close haemodynamic monitoring. Vasoactive agents as indicated.
- Correction of anaemia and coagulopathy – maintain haemocrit 0.25 – 0.3 to keep blood viscosity low. INR 2, APTT 50 secs, Fibrinogen above 0.5 g/L and Platelets above 30 x 109/L.
- Fluid and electrolyte management – appropriate negative fluid balance day 1 decreases risk of pulmonary complications. Fluid overload may aggravate graft congestion and oedema caused by ischaemic-reperfusion. Electrolyte imbalances are common and need to be corrected.
- Correction of metabolic abnormalities – hypoglycaemia is an ominous sign of compromised liver recovery, hyperglycaemia also may occur, acid-base abnormalities also occur
- Early weaning from mechanical ventilation – associated with better outcome but not feasible in patients with respiratory failure, haemodynamic instability, pulmonary oedema, primary graft dysfunction, encephalopathy etc. Unsucessful early extubation may result in impaired oxygen delivery to transplanted liver
- Monitoring of graft function LFTs, lactate, BSL, coagulation, hepatic artery doppler Early detection of surgical complications – bleeding
- Infection prophylaxis
- Housekeeping including analgesia (PCA) and appropriate nutrition plan
- Other – ICP monitoring if decompensated CLD pre-op
b) Despite weaning sedation he remains unresponsive 12 hours after ICU admission. What are the possible causes?
- Delayed metabolism of sedative / anaesthetic drugs
- Metabolic derangements – hypoglycaemia, hyponatraemia, hyperosmolar syndrome
- Hepatic encephalopathy
- Hypoxic-ischaemic cerebral injury
- Intracerebral haemorrhage
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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