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Acute liver failure (ALF). Bengt-Åke Henriksson CIVA SU/S Göteborg. William Bernal Liver Intensive Care Unit King´s College Hospital London. Acute vs Chronic liver failure. Encephalopathy /progressive vs fluctuating/ Cerebral oedema /yes vs no/. Case 1. 42 year old woman

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acute liver failure alf

Acute liver failure (ALF)

Bengt-Åke Henriksson

CIVA

SU/S

Göteborg

William Bernal

Liver Intensive Care Unit

King´s College Hospital

London

acute vs chronic liver failure
Acute vs Chronic liver failure
  • Encephalopathy /progressive vs fluctuating/
  • Cerebral oedema /yes vs no/
case 1
Case 1
  • 42 year old woman
  • Analgetics due to a Whiplash injury
  • An earlier suicide attempt
case 1 cont
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 cont5
ICU

Spontaneous breathing

Hypoxia

X-ray normal

Hypotension

RLS 4

Oliguria

Treatment

Intubation

Colloids, Crystalloids

Inotropic support

Case 1 cont.

First 24 hours in hospital

case 1 cont6
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

Laboratory

Paracetamol/se 750 mmol/l

Myoglobin/se 86600 g/l

Case 1 cont.
case 1 cont7
ICU

Spontaneous breathing

Hypoxia

X-ray normal

Hypotension

RLS 4-5

Anuria

CT brain normal

Treatment

Intubation

Colloids, Crystalloids

Inotropic support

Mannitol, Furosemid

Antibiotics

Acetylcysteine

Case 1 cont.

First 24 hours in hospital

case 1 cont su s
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
intensive care
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
Acute liver failure!
  • Support
    • CNS
    • Respiration
    • Circulation
    • CRRT/MARS
    • Coagulation
    • Infection
    • Metabolism
slide14
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
Respiration
  • Intubate before transport to transplantation centre
  • Avoid high PEEP
circulation
Circulation
  • Optimise blood volume
  • Optimise vascular tone
  • Cardiac support
  • Steroids
crrt mars
CRRT/MARS
  • Early CRRT
    • Reduce oedema
  • High ICP
    • Ultrafiltration
  • MARS?
coagulation
Coagulation
  • When bleeding
    • Plasma, Thrombocytes, Fibrinogen, NovoSeven®
    • Specific treatment
  • In desperate situations
    • Plasmapheresis
infection
SIRS due to

FHF

Sepsis

Prophylaxis

Bacteria

Fungi

Daily cultures

Infection
metabolism
Metabolism
  • Hypoglycemia
  • Hyperlactatemia
  • Metabolic alkalosis
daily laboratory tests
Daily laboratory tests
  • Phosphate/se
  • Amylase/se
  • Lactate/se
  • TEG
  • Indocyanine elimination
  • Daily cultures
medical treatment
Medical treatment
  • Acetylcystein®
  • Konakion®
  • Pantoloc®
  • Meronem®
  • Ambisome®/Diflucan®
  • ProEpanutin®
case 1 cont su s24
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 cont. - SU/S
case 2 19 9
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

Temperature 41.7° C

Unconscious

Pupils dilated

Hyperventilation (40 /min)

Heart rate 180/min

Diagnosis

Heat stroke

Case 2 cont. 19/9
case 2 cont 21 9
Septicemia

Staphylococcus aureus

Metabolic acidosis

Lactate 18.5 mmol/l

Creatinine 421 mol/l

ALAT 234 kat/l

Bil 106 mol/l

APTT 66s

PK(INR) 3.5

Thrombocytes 29 x 109 /l

Treatment

Intubation and on ventilator

Midazolam

Inotropic support

Acetylcysteine

Antibiotics

CRRT

Case 2 cont. 21/9
case 2 cont 25 9
Transferred to SU/S

Comatous, RLS 7-8

PEARRL

On ventilator FiO2 0.35

No inotropic support

Low urine output

PRISMA/MARS

CT-scan normal

Laboratory

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. 25/9
case 2 cont 29 9
Bleeding from right lung

Treatment

Plasma

Fibrinogen

Surgical tracheostomy

Bleeding from tracheostoma

Case 2 cont. 29/9
normal coagulation
Normal coagulation

II

X

VIII/vWF

TF

VIIa

Xa

IIa

Va

TF-Bearing Cell

VIIIa

VIIa

TF

IX

V

Va

Platelet

II

X

Fibrinogen

IIa

Fibrin

IXa

VIIIa

Xa

Va

XIIIa

Activated Platelet

Fibrin

novoseven
NovoSeven

X

II

TF

rFVIIa

Xa

IIa

Va

TF-Bearing Cell

rFVIIa

TF

IX

V

Va

Platelet

II

X

Fibrinogen

rFVIIa

Fibrin

IIa

Xa

Va

IXa

XIIIa

Activated Platelet

Fibrin

haemostasis
Haemostasis
  • FFP
    • 10-15 ml/kg
  • Thrombocytes
    • 2-4 units à 300 x 109 /l
  • Fibrinogen
    • 1-2 g
  • Blood
    • Hb ~100 g/l
  • NovoSeven®
    • 100 g/kg

Fibrin