BCC4: Clive Woolfe on Chronic Liver Disease

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Clive Woolfe, Irishman and RPA Intensivist, speaks at Bedside Critical Care Conference. In this podcast, he gives an overview of the prognostication and management of chronic liver disease. See …

Clive Woolfe, Irishman and RPA Intensivist, speaks at Bedside Critical Care Conference. In this podcast, he gives an overview of the prognostication and management of chronic liver disease. See www.intensivecarenetwork.com for the podcast.

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Transcript

  • 1. Chronic Liver Disease BCC, Cairns, September 2013 Clive Woolfe
  • 2. Definitions Organ
  • 3.   Support Prognositicating... Facts
  • 4.   and
  • 5.   Figures
  • 6. Cirrhosis “late stage of progressive hepatic fibrosis” Death from Portal Hypertension, progressive MOF, not encephalopathy
  • 7. The economic cost and health burden of liver disease in Australia January 2013
  • 8. Child-Turcotte-Pugh Abdominal Surgery Mortality (%) ! 10 ! 30 ! 82
  • 9. MELD Model for Endstage Liver Disease 9.57 x ln(Creatinine) + 3.78 x ln(Bilirubin) +11.2 x In(INR) + 6.43
  • 10. MELD Model for Endstage Liver Disease 9.57 x ln(Creatinine) + 3.78 x ln(Bilirubin) +11.2 x In(INR) + 6.43 20 40 60 80 100 0 10 15 20 25 30 40 83 80 78 74 71 90 81 63 42 21 Waiting List Survival 1 year post OLTx Survival MELD Score %
  • 11. Terminal Disease... progressive MOF
  • 12. ICU
  • 13. ICU Reversible precipitant? ! Organ support as a bridge to transplant
  • 14. Precipitants Look for Reversibility Drugs BDZ Narcotics Ammonia Diet Infection GI bleeding Hypokalaemia Constipation Metab Alkalosis Vascular Occlusion Porto-systemic shunts NH3 Dehydration V&D Hemorrhage Diuretics Paracentesis HCC Alcohol
  • 15. Variceal Haemorrhage Median Follow Up 2.5 years
  • 16. No survival advantage 2x Encephalopathy ?
  • 17. Organ support
  • 18. Neurological NH3 Serial Examination Hippus Clonus Hyperreflexia
  • 19. Efficacy of “Treatments” for HE +
  • 20. Respiratory Bleeding Sepsis ?Hepato-pulmonary Syndrome Porto-Pulmonary Hypertension PAP Massive TidalVolumes Paracentesi
  • 21. CVS E. Coli
  • 22. Renal/Fluids Renal hypoperfusion RAA activation Low Intravascular Volume vs. High TBW Hepatic CongestionHepatorenal Syndrome Late presentation: Low muscle mass Low urea production “Euvolaemia”
  • 23. Gastrointestinal
  • 24. Precipitating Event SBP Prophylaxis Sepsis ! 24% of cirrhotic inpatients RTI > UTI > C.Diff Mortality increase: 39 to 49%
  • 25. Finally... ICU Reversible precipitant? ! Organ support as a bridge to transplant
  • 26. ICU Reversible precipitant? ! Organ support as a bridge to transplant