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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. Encephalopathy /progressive vs fluctuating/ Cerebral oedema /yes vs no/. Case 1. 42 year old woman

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Acute liver failure (ALF)

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  1. Acute liver failure (ALF) Bengt-Åke Henriksson CIVA SU/S Göteborg William Bernal Liver Intensive Care Unit King´s College Hospital London

  2. Acute vs Chronic liver failure • Encephalopathy /progressive vs fluctuating/ • Cerebral oedema /yes vs no/

  3. Case 1 • 42 year old woman • Analgetics due to a Whiplash injury • An earlier suicide attempt

  4. Case 1 cont. • Ambulance record • Unconscious lying on the floor • Cold and pale. Spontaneous breathing • RLS 4 • SAP ~80 mmHg • Transferred to hospital

  5. 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

  6. 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.

  7. 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

  8. 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

  9. Urgent call for LTx

  10. Need for ICU RLS≥2

  11. Team work

  12. Intensive care • Support vital functions • Avoid complications • Identify patients with a bad prognosis • Optimal conditions for liver regeneration • Optimal conditions for transplantation

  13. Acute liver failure! • Support • CNS • Respiration • Circulation • CRRT/MARS • Coagulation • Infection • Metabolism

  14. 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

  15. Respiration • Intubate before transport to transplantation centre • Avoid high PEEP

  16. Circulation • Optimise blood volume • Optimise vascular tone • Cardiac support • Steroids

  17. CRRT/MARS • Early CRRT • Reduce oedema • High ICP • Ultrafiltration • MARS?

  18. Coagulation • When bleeding • Plasma, Thrombocytes, Fibrinogen, NovoSeven® • Specific treatment • In desperate situations • Plasmapheresis

  19. SIRS due to FHF Sepsis Prophylaxis Bacteria Fungi Daily cultures Infection

  20. Metabolism • Hypoglycemia • Hyperlactatemia • Metabolic alkalosis

  21. Hepatectomy??

  22. Daily laboratory tests • Phosphate/se • Amylase/se • Lactate/se • TEG • Indocyanine elimination • Daily cultures

  23. Medical treatment • Acetylcystein® • Konakion® • Pantoloc® • Meronem® • Ambisome®/Diflucan® • ProEpanutin®

  24. 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

  25. Case 1; Laboratory data

  26. Case 2 19/9 • 24 year old soldier • The night before abdominal discomfort • Collapsed during a cross-country race • Found unconscious with convulsions

  27. Emergency department Temperature 41.7° C Unconscious Pupils dilated Hyperventilation (40 /min) Heart rate 180/min Diagnosis Heat stroke Case 2 cont. 19/9

  28. 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

  29. 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

  30. Bleeding from right lung Treatment Plasma Fibrinogen Surgical tracheostomy Bleeding from tracheostoma Case 2 cont. 29/9

  31. 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

  32. 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

  33. 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

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