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					Acute liver failure (ALF)

William Bernal Liver Intensive Care Unit King´s College Hospital London

Bengt-Åke Henriksson CIVA SU/S Göteborg

Acute vs Chronic liver failure



Encephalopathy /progressive vs fluctuating/ Cerebral oedema /yes vs no/



Case 1
  

42 year old woman Analgetics due to a Whiplash injury An earlier suicide attempt

Case 1 cont.


Ambulance record
    

Unconscious lying on the floor Cold and pale. Spontaneous breathing RLS 4 SAP ~80 mmHg Transferred to hospital

Case 1 cont.
First 24 hours in hospital


ICU
– –



Treatment
– – –

Spontaneous breathing Hypoxia


X-ray normal

Intubation Colloids, Crystalloids Inotropic support

– – –

Hypotension RLS 4 Oliguria

Case 1 cont.


Laboratory
– – – – – –



Laboratory
– –

ASAT 290 kat/l ALAT 190 kat/l Bil 41 mol/l Amylase 29.2 kat/l PK(INR) 3.4 pH 6.97, BE -27

Paracetamol/se 750 mmol/l Myoglobin/se 86600 g/l

Case 1 cont.
First 24 hours in hospital


ICU
– –



Treatment
– – – – – –

Spontaneous breathing Hypoxia


X-ray normal

– – – –

Hypotension RLS 4-5 Anuria CT brain normal

Intubation Colloids, Crystalloids Inotropic support Mannitol, Furosemid Antibiotics Acetylcysteine

Case 1 cont. - SU/S
 

Ventilator 100% O2
–

Pulmonary oedema




Hypotension, CO 7-8 l/min Normal pupils but dilate after some hours
–

RLS 7-8



Anuric PK(INR) 5,2

Urgent call for LTx

Need for ICU

RLS≥2

Team work
Hepatologist

ICU doctor
coordinator

Surgeon

Intensive care
    

Support vital functions Avoid complications Identify patients with a bad prognosis Optimal conditions for liver regeneration Optimal conditions for transplantation

Acute liver failure!


Support
– – – – – – –

CNS Respiration Circulation CRRT/MARS Coagulation Infection Metabolism

CNS


Control of ICP
–

ICP monitoring
–

PK(INR) <1.4 – TPK >50 x 109 /l
  

RLS ≥4 or sedated patient on ventilator ICP <20 mmHg CPP >50-60 mmHg



EEG monitoring
–

Sedated patient on ventilator

Respiration
 

Intubate before transport to transplantation centre Avoid high PEEP

Circulation
Optimise blood volume  Optimise vascular tone  Cardiac support  Steroids


CRRT/MARS
  

Early CRRT
–

Reduce oedema

High ICP
–

Ultrafiltration

MARS?

Coagulation


When bleeding
– –

Plasma, Thrombocytes, Fibrinogen, NovoSeven® Specific treatment Plasmapheresis



In desperate situations
–

Infection


SIRS due to
– –



Daily cultures

FHF Sepsis Bacteria Fungi



Prophylaxis
– –

Metabolism





Hypoglycemia Hyperlactatemia Metabolic alkalosis

Hepatectomy??

Daily laboratory tests
  


 

Phosphate/se Amylase/se Lactate/se TEG Indocyanine elimination Daily cultures

Medical treatment
  


 

Acetylcystein® Konakion® Pantoloc® Meronem® Ambisome®/Diflucan® ProEpanutin®

Case 1 cont. - SU/S
    

Ventilator 100% O2
–

   

Pulmonary oedema

Hypotension, CO 7-8 l/min Normal pupils but dilate after some hours Anuric PK(INR) 5,2



Norepinephrine, Dobutamine CRRT Barbiturates Intracranial pressure monitoring device not available Antibiotics

Case 1; Laboratory data
08-feb
Urgent call

09-feb

10-feb

11-feb

12-feb

13-feb

14-feb

18-feb

ASAT ALAT Bil APTT PK(INR) TPK Lactate Phosphate Coma

140 63 38 85 5,2 213 13 1,6 4

120 54 61 78 5,2 116 12 0,81 4

75 35 110 72 4,2 28 9

42 22 170 65 3,2 21 10

18 23 260 71 2,3 22 4

6,5 9,4 330 45 2,0 27 5 0,16

2,2 4,6 360 56 2,0 20 5

1,5 1,0 560 37 1,7 51 3,5

4

4

4

3

3

3

Case 2
   

19/9

24 year old soldier The night before abdominal discomfort Collapsed during a cross-country race Found unconscious with convulsions

Case 2 cont.


19/9


Emergency department
– – – – –

Diagnosis
–

Temperature 41.7° C Unconscious Pupils dilated Hyperventilation (40 /min) Heart rate 180/min

Heat stroke

Case 2 cont.


21/9


Septicemia
–

Treatment
–

Staphylococcus aureus
 

Metabolic acidosis Lactate 18.5 mmol/l
–
– – –

Intubation and on ventilator


Midazolam

–
– – – – –

Creatinine 421 mol/l ALAT 234 kat/l Bil 106 mol/l APTT 66s PK(INR) 3.5 Thrombocytes 29 x 109 /l

Inotropic support Acetylcysteine Antibiotics CRRT

Case 2 cont.


25/9


Transferred to SU/S
–

Laboratory
– – – – – –

Comatous, RLS 7-8


PEARRL

–

–
– – –

On ventilator FiO2 0.35 No inotropic support Low urine output PRISMA/MARS CT-scan normal

ASAT 12 kat/l ALAT 14 kat/l Bil 300 mol/l PK(INR) 3.4 Fibrinogen 1.4 g/l Lactate 3 mmol/l

Case 2 cont.


29/9


Bleeding from right lung

Treatment
– – –

Plasma Fibrinogen Surgical tracheostomy


Bleeding from tracheostoma

Normal coagulation
X TF VIIa

II
Xa Va IIa

VIII/vWF

TF-Bearing Cell IX VIIa TF X IXa VIIIa

VIIIa V Va
Platelet

II
Xa Va

Fibrinogen

IIa

Fibrin XIIIa
Fibrin

Activated Platelet

NovoSeven
X TF rFVIIa

II
Xa Va IIa

TF-Bearing Cell
IX rFVIIa TF X II IIa

V

Va
Platelet

Fibrinogen

IXa

rFVIIa

Xa Va Activated Platelet

Fibrin
XIIIa Fibrin

Haemostasis
 

FFP
–

10-15 ml/kg 2-4 units à 300 x 109 /l 1-2 g Hb ~100 g/l 100 g/kg
Fibrin

Thrombocytes
–




Fibrinogen
–

Blood
–



NovoSeven®
–


				
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posted:12/23/2009
language:English
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