【持续性肾脏替代治疗CRRT英文ppt课件】Liver failure.ppt

Liver failure;Cause Agent responsible Viral Hepatitis A, B, D E, others Drug related Idiosyncratic and dose related Toxins Carbon tetrachloride, Phosphorous Amanita phalloides Vascular events Ischemic hepatitis, Budd-Chiari, VOD, heat shock liver Other Pregnancy related, Wilson disease, lymphoma; 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;Renal failure;Infection : ALF;Vasopressors in ALF;Results stratified according to blood pressure on day of SST;Encephalopathy;Hepatic encephalopathy in CLD ;Progressive neuropsychiatric syndrome, progressive neural inhibition Occurs in both acute and chronic liver disease Clinical state may change very rapidly ;Larsen Neurochem International 2004 (44) ;Increased ammonia in cerebral deaths : splanchnic ammonia production Larsen et al Hepatology 1998 NH4 cut off 124 .pH, cerebral oedema + NH4 predict outcome Bhatia V Gut 2005 Partial pressure NH4 correlates with level of encephalopathy Kramer Hepatology 2000:21 CBF variable : loss of autoregulation to pressure Terlipressin in ALF Shawcross et al; Hepatology 2004;39(2):464-70 ;Jalan et al Gastroenterology 2004;27:1338 Cooled to 32-33 o C ;Reduction in ICP in treatment group (p0.005);Agitation and airway management Grade III : Intubate ventilate and sedate with opiate and propofol Control ventilation - avoid alkalosis Position - 10 to 20 degrees head up Insert reverse jugular line: JV sat 55 to 80% Tight control of glucose, K, pH, Na (145-150 mmol/L) Murphy et al Hepatology 2004;39(2):464-70 Ammonia : early CRRT MAP 65 : frequently not autoregula