Chronic Liver Failure - Management
Management – general
Patients with liver failure often deteriorate quickly. If patients are not unwell enough for resuscitation beds they should be placed in a highly visible bed with a cardiac monitor. For patients who require intubation / inotropic support / ICU care one must assess the appropriateness of these interventions, the reversibility of the situation and the prognosis for the patient. The Child-Pugh score can be used to help determine prognosis.
Management - specific
Thiamine IV 200mg stat and continue IV 200mg 8 hourly – there is no consensus on route, dose, frequency. Patients with Wernickes encephalopathy may need doses up to 500mg IV
Multivitamins for nutritional deficiencies, replace electrolytes
Glucose as have lost gluconeogenic powers – give thiamine prior to glucose load
Alcohol withdrawal scale and oral diazepam
Lactulose 20mLs QID
Education about abstinence
Work out Maddreys Discriminant Function (MDF) score. Patients with MDF ≥32 have a poor prognosis. Discuss with gastroenterology. They may benefit from:
Steroids – minimal data but there is a suggestion that steroids have a protective effect - start 40mg/day if no contraindications.
Anticytokine therapy – pentoxifylline – oral phosphodiesterase inhibitor which decreases production TNF? and other cytokines.
Indications for paracentesis include abdominal pain and SOB
Check inr/plt and for relative contraindications like adhesions, bowel obstruction
Send sample for albumin, cytology, cell count, culture
If large amount (>6L) to be drained then replace volume with human albumin solution (no evidence for use if less than this). Once paracentesis complete 100mLs 20% albumin / 3l ascites.
Na restriction (plus water restriction if Na
Spironolactone +/- frusemide
Link to Life In The Fast Lane Paracentesis video
Spontaneous Bacterial Peritonitis (SBP)
SBP is infection of ascitic fluid without clear source such as perforation / abscess (secondary bacterial peritonitis).
Diagnosis – Ascitic fluid - Polymorph cell count >250cells/mm? or positive fluid culture.
Typical organisms Klebsiella, E coli, Strep pneumoniae.
Treatment - If SBP suspected treat empirically with Cefotaxime 2g 8 hourly.
Stop ? blockers – it has been found non selective ? blockers increase haemodynamic instability, time of hospitalisation, and risks for hepatorenal syndrome and acute kidney injury.
PO vit K 10mg TDS
Platelet transfusion if plt
Active haemorrhage FFP +/- recombinant factor VIIa - discuss with Haematologist
Lactulose 20mLs QID
Early intubation if required to protect airway. Prior to this one must first make an assessment about the appropriateness of this intervention.
- Link to grades
Caused by extreme renal artery vasoconstriction in setting of splanchnic vasoldilation, low cardiac output and low effective plasma volume.
Plasma expansion with albumin (100mLs 20% HAS) +/- haemodialysis plus vasoactive agents like octreotide or norad.
Paracentesis has been found to improve renal function in volume resuscitated patients.
Hepato-pulmonary syndrome (HPS)
Tense ascites can cause pleural effusions and splint the diaphragm however true HPS is a disorder of pulmonary vascular dilatation and shunting.
Supplemental oxygen mainstay of treatment.
For refractory hypoxaemia, liver transplant is considered and higher priority given to those with liver failure and HPS.