Liver Service Transfer / Referral

Referral to liver service (any of the following)

• Creatinine >200
• Oliguria
• Acidosis pH<7.3  – persistent
• INR >3 at 48 hrs or >4.5 at any time
• Hypoglycaemia
• Encephalopathy (any grade)
• Severe thrombocytopenia (vague on values)

Remember the 3s and EncephalopaTHREE (ph 7.3, INR>3, BSL of 3.9 less, Encephalopathy)

Hepatic Encephalopathy

• Delirium
• Psychomotor slowing
• Cognitive/ concentration impairment
• Circadian disturbance
• Hepatic flap
  • textbook stuff, but relatively late sign
  • described as negative myoclonus and loss of postural tone (Dunn’s)
  • slow frequency (3-5 Hz)
• Hyper-reflexia & extensor posturing
• Grading (West Haven Criteria)
  • Grade 1: Changes in behaviour with minimal change in level of consciousness
  • Grade 2: Gross disorientation, drowsiness, possibly asterixis, inappropriate behaviour
  • Grade 3: Marked confusion, incoherent speech, sleeping most of the time but rousable to vocal stimuli
  • Grade 4: Comatose, unresponsive to pain; decorticate or decerebrate posturing

King’s College Criteria (paracetamol specific)

RIPE

• Renal failure – creatinine > 300
• INR > 6.5
• pH < 7.30 (arterial)
• Encephalopathy (grade 3/4)

John Currie

Initial undergraduate training in Southampton UK before moving to Australia. Current ACEM and CICM trainee Perth, WA. Additional interests in Diving and Hyperbaric medicine