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Liver study day @ ICS

Acute liver failure = syndrome of coagulopathy + jaundice + encephalopathy

Reduced glutathione reserves if poor nutrition, neuromuscular disorders

Raised ALT/AST found in 40% of patients taking ‘normal’ max dose of paracetamol 2 weeks.

NAC paracetamol OD. If in doubt of level, GIVE and continue. Giving ANYTIME after significant paracetamol level is beneficial.

In hyperacute ALF cerebral oedema predomiantes. With positive physchotic features i.e. agitated, delirium. Inter cranial hypertension carries high mortality.

Assessment

Viral screen

Autoimmune screen

NH3 – measurable and the trend. >200 predicts ICH. <75 is rare

Treatment

ICH:

Hypertonic saline. 3-30% NaCl. Aim for Na 145-155. Sedate + ventilate, normal CO2, CPP 60-80.

CVVHDF – removing NH3 affords CVS stability, irrespective of renal failure. High volume ultrafiltration

Steroids. Improve CVS stability, no change in outcome.

AoCLF: Terlipressin, Antibx, lactulose, Hb>7, plt > 50, fib >1

Sengstaken Tube:

50ml in stomach balloon then pull back +/- CXR

Then approx 350ml in stomach balloon, then CXR. Rarely need oesophageal balloon

TIPPS – risk of encephalopathy for reduced risk of bleeding.

Principles of some liver units:

Offer 48-72 hours of ‘trial of therapy’ then reassess. Reasonable to offer full support, including renal replacement therapy (‘all or nothing’ approach), then reassess. Though renal failure is a bad prognostic sign, it should not be a self-fulling prophecy.

Good MDT working

Question is : can we get this patient through ICU to discharge to assessment for liver transplant? What is exit/end-game/long term plan?

NAC in non-paracetamol ALF is ‘routine’ (though not in Acute on Chronic Liver failure)

Refer+/-transfer to liver unit early, preferably prior to needing CVVHDF

‘Early trache’

 

SCORING, PROGNOSTICATION, PLANNING

Prognosis in ALF – acuteness? Speed of deterioration is important. Age? Burden of MODS

Markers of high severity: encephalopathy, INR>6.5, creatinine > 600

www.kingsalfpredictor.org

CLIF-SOFA

https://gut.bmj.com/content/gutjnl/early/2017/01/04/gutjnl-2016-312670.full.pdf

Change in SOFA score at 48 hours probably best predictor

Validation of CLIF-C ACLF score to define a threshold for futility of intensive care support for patients with acute-on-chronic liver failure

https://ccforum.biomedcentral.com/articles/10.1186/s13054-018-2156-0

http://www.efclif.com

Advanced Care Planning required patient focussed care and goal setting. doi:10.1002/hep.29731

Other thoughts

When looking at creatinine and AKI consider underlying muscle mass (which is likely to be low)

Hepatorenal syndrome: urinary Na+ low. Terlipressin + Albumin

ATN: urinary Na+ high

SBP if WCC>250/mm3

Normal liver -> NAFLD –(inflammation/scarring)-> NASH -> cirrhosis

https://www.basl.org.uk

Nutrition

Aim to reduce protein breakdown as it is a catabolic state. Refeeding occurs due to gluocose load rather than protein. Unusual requirement is 25-30kcal/kg/day. In decompensated liver disease it is 35-40kcal/kg/day. Protein 1.2-1.5g/kg/day.

ESPEN guidelines:

https://www.espen.org/guidelines-home/espen-guidelines

https://www.espen.org/files/ESPEN-Guidelines/ESPEN_Guideline_on_clinical_nutrition_in_-ICU.pdf

Some stuff on Procalcitonin

Bottomline:

<0.2 unlikely to be bacterial sepsis (though has a lag-time of 2-4 hours from onset)

>0.5 likely to be bacterial sepsis

<0.5 consider stopping antibiotics

Pro-calcitonin guided antibiotic therapy may confer slight survival benefit and reduced lower antibiotic duration i.e. better stewardship

 

Links:

https://lifeinthefastlane.com/ccc/procalcitonin/

https://ccforum.biomedcentral.com/articles/10.1186/s13054-018-2125-7