【持续性肾脏替代治疗CRRT英文精品课件】Liver failure.pptVIP

Liver failure Decompensated chronic liver disease Decompensation with sepsis Bacterial peritonitis : Rx as “peritonitis” Bacteraemia, chest, urine Variceal bleed : frequently septic, endoscopic skills ± TIPS Encephalopathy Hepatorenal failure Alcoholic hepatitis : steroids, pentoxifylline, feed, delta bilirubin Differential with ALF : History Pattern of LFT’s Imaging : ultrasound, CT scan Biopsy : vary rarely indicated Liver trauma Multi system disease Coagulopathy INR important prognostic indicator in established ALF Platelet dysfunction DIC - rare Metabolic Insulin resistance : Clarke et al Hepatology Hyperlactataemia :Bernal et al Lancet 2002 : useful to track Liver net producer of lactate Murphy et al Crit Care Med 2001 P04, Mg, Na, glucose, K, pH High incidence of pancreatitis Nutrition Frequent poor recent oral intake ± vomiting No evidence for protein restriction in either acute or CLD Gastric prophylaxis Increased metabolic requirements Walsh et al CCM 2000;28(3):649-54 Renal failure Common 45% of all cases Multifactorial - frequently pre renal, ATN rather than HRS Role of intra-abdominal pressure Specific associations with viral disease, alcohol, auto-immune CRRT or slow haemodialysis is ideal Anticoagulation epoprostenol, heparin, regional anticoagulation, citrate Infection : ALF Impaired innate and cellular immunity Bacterial infection 335 of 887 patients (550 episodes) Severe sepsis 58% mortality Septic shock 98% mortality Fungal infection 99 of 887 : 11% : 64% mortality Rolando et al Hepatology 2000 32:734, 31(4):872 Components of SIRS associated with encephalopathy Rolando et al Hepatology 2000;32:734-9, Vaquero et al Gastroenterology 2003;125:755-64, Shawcross D et al J Hepatol inpress Cultures +++ Antibiotics : broad initially - 5/7 course Antifungals No benefit to routine prophylaxis or Selective gut decontamination Rolando et al Semin Liver Dis 1996;16:389-402, Rolando et al Liver Trans Surg 1996;2:8-13 Vasopressors i