10 - Hepatic Encephalopathy and Acute Liver Failure Flashcards Preview

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1

If the liver recovers

It regenerates completely

2

If the liver fails acutely

Patient dies within 4 - 7 days

3

What do you see in halothane-induced hepatic failure?

Massive Necrosis
Little bile ducts re-forming!
Sadly, most patients don't make it long enough for the regeneration!!!!

4

Acute Liver Failure - Syndrome

Altered Mentation (Hepatic Encephalopathy)
Coagulopathy (INR >- 1.5)
Acute Illness (

5

Acute-on-Chronic Liver Disease

Never has cerebral edema
Refers to when someone with chronic liver disease has an acute failure.

6

Acute Liver Failure - Management

Establish Diagnosis (INR, AMS, new hepatic illness)
Determine Etiology (history, Labs)
Estimate Severity (Exam, Labs)

7

Acute Liver Failure - How do we treat different etiologies?

Acetaminophen? --> Tx = N-Acetyl Cysteine
Mushrooms (not the magic kind. The dad kind.) ? --> Tx = Penicillamine/silibinin antidote
Wilsons? (Elevated bilirubin, low AP, Increased Ucu)? --> Tx = OLTx
Drug-Induced/Viral/Indeterminate? --> Tx = Good Intensive Care

8

Acute Liver Failure - How do we estimate severity?

ICU Monitoring / Management
Supportive Care
Transplant evaluation / Planning (start early!)

9

Fulminant Hepatic Failure - Etiologies

Viruses (HAV, HBV, HDV, HEV)
Other viruses you can't find (they are hepatotrophic)
Drugs (Acetaminophen)
Toxins (Amanita Mushrooms)
Metabolic Diseases (Wilson's)
Ischemia (Budd-Chiari)
Others (AFLP, Heat Stroke, Autoimmune)
Cryptogenic

10

Fulminant Hepatic Failure - Acetaminophen

Billion dollar product - OTC more than 300 brands
Unique dose-related toxin
100,000 calls to Poison Control annually
50,000 ER visits/year
10,000 hospitalizations/year
500 deaths/hear
Current assay measures only the acetaminophen parent compound, not the toxic metabolite

11

Acute Liver Failure - Other Drugs

Anti-TB Drugs
8 INH without other anti-TB drugs
2 with other non-TB drugs
5 INH + rifampin + pyrazinamide
1 INH + Ethambutol
2 rifampin + pyrazinamide

Sulfa-related drug
TMP-Sulfa
Sulfadiazine
Sulfasalazine

Other antibiotics
1 Amox-clavulanate
6 Nitrofurantoin
1 Ciprofloxacin
1 Doxycycline
1 Itraconazole

Misc
Phenytoin 6
Valproate 1
PTU 4
Disulfiram 4
Atorvastatin 1
Cerivastatin 2
Bromfenac 4
Troglitazone 4
Herbals and/or dietary supplements 9
(including 2 Kava-Kava
HAART 2
Halothane/Isoflurane 2

12

Fulminant Hepatic Failure - Therapy

ICU
Correct Complications
Avoid FFP, sedatives until decision on transplant reached
Short trial of lactulose may help
Transfer to transplant center before complications develop

13

Fulminant Hepatic Failure - Infection

Happens in MOST patients!! (80% of patients)
Documented bacteremia in 20 - 25%
Secondary to gut translocation, decreased ReticuloEndothelial function and instrumentations
Gram negatives, Staph, Strep with fungal infection in up to 33%

14

Fulminant Hepatic Failure - Infection Plan

Culture all patients broadly with a low threshold for empiric antibiotics
Prophylactic antifungals if renal failure or on abx already.

15

Fulminant Hepatic Failure - Renal Failure

Occurs in up to 33% of patients
Often multifactorial - Volume depletion, ATN, hepatorenal
Urine sodium may be helpful (if it's low)
Avoid CT contrast, empiric aminoglycosides
Since patients tolerate volume overload poorly, CVP or PA monitoring is important!
If oliguria persists with normal CVP --> CVVH

16

It's not hepatorenal

If they don't have massive portal HTN (either ascites or acute - vessel thrombosed or acute liver failure)

17

How do we make Acute Liver Failure-induced Renal Failure worse?

CT Contrast (dangerous!)
Aminoglycosides
NSAIDS
Flood them with fluids! - Leads to cerebral edema!!

18

What is the only imaging you should order in the case of Acute Liver Failure?!

Ultrasound with doppler examination of the hepatic vessels

Unless you suspect that the reason is massive malignant infiltration of the liver

19

Indication for dialysis in acute liver failure

Normal CVP
Not making urine

20

What happens if you fill an Acute Liver Failure patient who has developed Renal Failure with fluids?!

Cerebral Edema

21

Complications in Acute Liver Failure that resolve on their own if the liver is transplanted

Infection
Renal Failure

22

Complications in Acute Liver Failure that DON'T resolve on their own if the liver is transplanted!!!!

Multi-Organ Failure
and
Cerebral Edema

Contraindications to Transplant!!!

23

Multi-Organ Failure

Can give ARDS, ATN, Peripheral Vasodilatation with Hypotension, and DIC

Difficult to separate from Sepsis

Can be a contraindaction to OLT (particularly ARDS)
Treatment is supportive only.

24

Acute Liver Failure - Contraindications to Transplant!!

Multi-Organ Failure
Cerebral Edema

25

Fulminant Hepatic Failure - Cerebral Edema

Most common cause of death in patients with Acute Liver Failure
Present in up to 80% of patients DYING with FHF
The remaining 20% died of septic shock.
Difficult to diagnose with CT, early monitoring essential
If untreated, leads to herniation. Transplantation is the only "cure" but it takes 48 hours to reduce the edema!
Barbiturates, mannitol, hyperventilation & elevation of the head MAY halp!

26

Fulminant Hepatic Failure - Timing of Transplantation

80% of patients with fulminant hepatic failure who survive successful liver transplants have them in the first 48 hours
Early transfer to transplant center is key
Role of extracorporeal liver assist devices inconclusive

27

Median waiting time of a Status 1 on the transplant list in the USA

1 1/2 days

28

Pediatric Acute Liver Failure

Syndrome same as adults
Etiology is different:

52% are indeterminate (probably non-A-through-C viral hepatitis)

Acetaminophen Origins - Often through therapeutic mistakes. Infant tylenol is more concentrated than children's tylenol. Also suicidal teens.

29

Indications for OLT in Fulminant Hepatic Failure

King's College Criteria:

Acetaminophen-Induced (higher rate of spontaneous recovery)

vs

Not Acetaminophen

30

Indications for OLT in Fulminant Hepatic Failure - King's College Criteria for Acetaminophen-Induced

Systemic pH 100 seconds
AND
Creatinine > 3.5 mg/dL in patient with Stage III or IV coma