acute liver failure - icmdoc.files.wordpress.com · acute liver failure carries high mortality...

Acute Liver Failure Dr Steve Gill Consultant in ICM and Anaesthesia Nottingham University Hospitals Follow me on twitter @ICMDoc

Objectives   Understand the definitions and common causes of

acute liver failure

  Discuss the clinical features and management options

  Describe the indications for referral to a transplant centre

  Consider the specific considerations for post-resection liver failure

Definitions

  Varying definitions

  Typically based on time from symptoms to encephalopathy

  Slower onset may be confused for chronic liver disease

Causes

  Viruses

  Drugs

  Autoimmune

  Others

Clinical features

Management - general   Airway/Breathing - for low GCS

  Circulation - typically high CO with low SVR

  ICP management

  Maintain glucose level

  Correct only coagulopathy if bleeding

  Antibiotics

  Nutrition

  CVVH

Management - specific

  n-acetylcystiene

  Lactulose

  Steroids

  Transplantation

When to refer   Paracetamol

  pH<7.3

Or all three of …

  INR>6.5

  Creatinine >300

  Grade III or IV encephalopathy

  Non-Paracetamol

  INR >6.5

Or 3 of …

  Age <11 or >40

  Bilirubin >300

  Jaundice to coma >7/7

  INR >3.5

  Drug toxicity

Post-Liver Resection Failure   Defined as “a postoperative acquired deterioration …

increased INR and bilirubin on or after day 5”

  Grade A - abnormal lab parameters but no change in management

  Grade B - change in normal post op management required but without invasive treatment

  Grade C - requiring invasive treatment

Risk factors for post-resection liver failure

  Size of resection

  Preoperative liver disease

  Ischaemia/reperfusion injury

Prevention

  Patient selection and surgical strategy

  Anaesthetic agent

  Minimise blood loss

  Insulin therapy

  Ischaemic preconditioning

Management   Optimise & support ABCDE

  Rule out vascular compromise

  Treat infection

  N-acetylcystine

  Nutrition & laxatives

  Reduce portal venous flow

  Rescue hepatectomy and transplantation

Any questions??

Summary   Acute liver failure carries high mortality especially in the

developing world where viral infection is the commonest cause

  Treatment is mostly supportive

  Post-resection liver failure can be risk assessed and steps take to prevent and treat it throughout the preoperative course

  Transplantation is effective in a number of situations but limited by donor availability

I will post links to this talk and relevant papers via twitter later today (hopefully) @ICMDoc