This document summarizes Julia Wendon's presentation on fluid management in liver disease and critical care. It discusses:
- Potential categories of liver dysfunction seen in critical care including primary and secondary liver injury.
- Issues related to various fluid types including dextrose, saline, colloids and albumin in conditions like acute liver failure, hepatic resection, and cirrhosis.
- Hemodynamic considerations in these conditions and how raised intra-abdominal pressure can affect cardiac preload and output.
- Management of complications like ascites, variceal hemorrhage, and hepatorenal syndrome.
- Studies on the use of albumin and vasoconstrictors in
Acute Kidney Injury-case management and discussion
AKI secondary to sepsis secondary to acute bacterial salphingitis vs TB salphingitis
KDIGO 2012 guidelines
AKI, harrison's 19th edition
Cirrhosis is a late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases and conditions, such as hepatitis and chronic alcoholism.
CASE PRESENTATION ONCIRRHOSIS OF LIVER WITH PORTAL HYPERTENSION, HEPATIC EN...Akhil Joseph
A DETAIL CASE PRESENTATION ON CIRRHOSIS OF LIVER WITH PORTAL HYPERTENSION, HEPATIC ENCEPHALOPATHY AND GRADE II OESOPHAGEAL VARICES WITH CONGESTIVE GASTROPATHY. LIVER CIRRHOSIS AND ALL ITS COMPLICATION IN A PATIENT.
Acute Kidney Injury-case management and discussion
AKI secondary to sepsis secondary to acute bacterial salphingitis vs TB salphingitis
KDIGO 2012 guidelines
AKI, harrison's 19th edition
Cirrhosis is a late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases and conditions, such as hepatitis and chronic alcoholism.
CASE PRESENTATION ONCIRRHOSIS OF LIVER WITH PORTAL HYPERTENSION, HEPATIC EN...Akhil Joseph
A DETAIL CASE PRESENTATION ON CIRRHOSIS OF LIVER WITH PORTAL HYPERTENSION, HEPATIC ENCEPHALOPATHY AND GRADE II OESOPHAGEAL VARICES WITH CONGESTIVE GASTROPATHY. LIVER CIRRHOSIS AND ALL ITS COMPLICATION IN A PATIENT.
Acute kidney injury is important topic for students.
the presentation covers all aspects including guidelines from KDIGO, harrison 20th edition and relevant articles.
COURTSEY - DEPARTMENT OF CRITICAL CARE
ABVIMS & DR RML HOSPITAL NEW DELHI.
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
This symposium provides an overview of the (r)evolution in intensive care medicine. The programme is based on lectures of 20 minutes where each speaker presents in two 10 minute talks (in der Beschränkung zeigt sich erst der Meister) the good things that happened in the last 40 years in critical care vs our mistakes or what is missing with respect to that topic. At the end of the session the speakers participate in an interactive round table discussion with online voting to get the audience involved. Will be discussed: Theoretical concepts, basic physiology and pathophysiology, monitoring, and future directions.
This symposium provides an overview of the (r)evolution in intensive care medicine. The programme is based on lectures of 20 minutes where each speaker presents in two 10 minute talks (in der Beschränkung zeigt sich erst der Meister) the good things that happened in the last 40 years in critical care vs our mistakes or what is missing with respect to that topic. At the end of the session the speakers participate in an interactive round table discussion with online voting to get the audience involved. Will be discussed: Theoretical concepts, basic physiology and pathophysiology, monitoring, and future directions.
This symposium provides an overview of the (r)evolution in intensive care medicine. The programme is based on lectures of 20 minutes where each speaker presents in two 10 minute talks (in der Beschränkung zeigt sich erst der Meister) the good things that happened in the last 40 years in critical care vs our mistakes or what is missing with respect to that topic. At the end of the session the speakers participate in an interactive round table discussion with online voting to get the audience involved. Will be discussed: Theoretical concepts, basic physiology and pathophysiology, monitoring, and future directions.
This symposium provides an overview of the (r)evolution in intensive care medicine. The programme is based on lectures of 20 minutes where each speaker presents in two 10 minute talks (in der Beschränkung zeigt sich erst der Meister) the good things that happened in the last 40 years in critical care vs our mistakes or what is missing with respect to that topic. At the end of the session the speakers participate in an interactive round table discussion with online voting to get the audience involved. Will be discussed: Theoretical concepts, basic physiology and pathophysiology, monitoring, and future directions.
This symposium provides an overview of the (r)evolution in intensive care medicine. The programme is based on lectures of 20 minutes where each speaker presents in two 10 minute talks (in der Beschränkung zeigt sich erst der Meister) the good things that happened in the last 40 years in critical care vs our mistakes or what is missing with respect to that topic. At the end of the session the speakers participate in an interactive round table discussion with online voting to get the audience involved. Will be discussed: Theoretical concepts, basic physiology and pathophysiology, monitoring, and future directions.
This symposium provides an overview of the (r)evolution in intensive care medicine. The programme is based on lectures of 20 minutes where each speaker presents in two 10 minute talks (in der Beschränkung zeigt sich erst der Meister) the good things that happened in the last 40 years in critical care vs our mistakes or what is missing with respect to that topic. At the end of the session the speakers participate in an interactive round table discussion with online voting to get the audience involved. Will be discussed: Theoretical concepts, basic physiology and pathophysiology, monitoring, and future directions.
This symposium provides an overview of the (r)evolution in intensive care medicine. The programme is based on lectures of 20 minutes where each speaker presents in two 10 minute talks (in der Beschränkung zeigt sich erst der Meister) the good things that happened in the last 40 years in critical care vs our mistakes or what is missing with respect to that topic. At the end of the session the speakers participate in an interactive round table discussion with online voting to get the audience involved. Will be discussed: Theoretical concepts, basic physiology and pathophysiology, monitoring, and future directions.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
QA Paediatric dentistry department, Hospital Melaka 2020Azreen Aj
QA study - To improve the 6th monthly recall rate post-comprehensive dental treatment under general anaesthesia in paediatric dentistry department, Hospital Melaka
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
Struggling with intense fears that disrupt your life? At Renew Life Hypnosis, we offer specialized hypnosis to overcome fear. Phobias are exaggerated fears, often stemming from past traumas or learned behaviors. Hypnotherapy addresses these deep-seated fears by accessing the subconscious mind, helping you change your reactions to phobic triggers. Our expert therapists guide you into a state of deep relaxation, allowing you to transform your responses and reduce anxiety. Experience increased confidence and freedom from phobias with our personalized approach. Ready to live a fear-free life? Visit us at Renew Life Hypnosis..
We understand the unique challenges pickleball players face and are committed to helping you stay healthy and active. In this presentation, we’ll explore the three most common pickleball injuries and provide strategies for prevention and treatment.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
1. I have no financial relationship(s) to disclose relevant to my
presentation.
julia.wendon@kcl.ac.uk
All Fluids are bad
The Liverand abdominal hypertension
Julia Wendon
Consultant Intensivist and Hepatologist
Institute of Liver Studies
Kings College Hospital
London
4. Fluids and liver disease
• 5% dextrose
• 20-50% dextrose
• N/ Saline / Hartmans / balanced crystalloids
• Colloids
• 4.5% albumin 20% albumin
• gelatins , starch
5.
6. Haemodynamics and issues
• ALF
– Initially all volume deplete – difficult to say fluid is
bad
– Risk of pancreatitis, gut oedema
– Stiff liver, develop ascites easily
• Hepatic resection
– Initially usually run dry
– Risk of small for size syndrome
– Portal inflow excessive to outflow
– Adequate but not excess fluid required
7. Haemodynamics of cirrhosis
• Group 1
– Ascites, central hyovolaemia, total blood volume
increased, usually diuresed ++ and low na and poor
kidneys
• Group 2
– RV volume / pressure overload, ascites and oedema,
cirrhotic cardiomyopathy, No PHT, usually high CI TPG
• Group 3
– Portopulmonary syndrome with normal RA, initially
maintained CI
8. Situations for discussion
• Acute liver failure
– Plasma exchange
• Ascites and drainage of said
• Variceal haemorrhage
• Hepatorenal failure
• Continuity between right heart, hepatic veins, liver
and sinusoids and back to portal vein and hence
guts – gut oedema, translocation
11. 11
Problems related to hypotonic solutions
Replace with albumin 20% to prevent PICD
Also consider risk of variceal bleeding
12.
13. Consider IAP and renal perfusion pressure
Options
1. Decrease IAP
2. Increase RPP
3. Improve central blood volume
RPP 61 to 67 mmHg
Potential risk of variceal
bleed ???
14. Budd^Chiari syndr
Deepak Joshi, Sujit Saha, Wi
Institute of Liver Studies, King’sColle
Keywords
abdominal compartment syndrome –
Chiari syndrome –intra-abdominal
hypertension –intra-abdominal press
Correspondence
Dr D. Joshi Institute of Liver Studies, K
College Hospital, London, SE5 9RS, U
Tel: 1 020 3299 2504
Fax: 1 020 3299 3899
e-mail: d.joshi@nhs.net
Received 16 November 2010
Accepted 12 May2011
DOI:10.1111/j.1478-3231.2011.025
Pre paracentesis
4-10 L +ive
Pressors
0.45 µg/kg/min
9 L ascites
Drained
Replaced 20%
Albumin 1.2 L
PLR : no increase
15.
16. Terlipressin ± albumin
Ortega et al Hepatology 2002;36:941
0.5 mg 4 hrly , albumin 1g/kg/body weight day 1 then 20 - 40
g/day
17. Sanyal A Gatroenterology 2008 :134:1360
Albumin daily 1g/kg
Martin-Llahi M Gastroenterology 2008:134
Data also for norepinephrine and Ptx and NAC
18. 10 trials only type I and II
Drug ± alb vs no intervention
Vasoconstrictors + Alb : Effect on mortality at 15 days but not at
30, 90 or 180 days RR 0.6 (0.37-0.97)
Terlipressin + Albumin vs Albumin : decreased mortality in type I
RR 0.83 (0.65-1.05)
19. MAP no relationship to
changes in GFR
MAP increased (>85)
Reversal of RAA, NE levels
Creatinine is
Dreadful measure
Of renal function
21. • 116 patients with cirrhosis and variceal bleed
• Endoscopy and sclerotherapy
• HVPG measured within first 24 hours: < or > 20
mmHg
• If > 20 randomized to TIPS or medical Rx
Monescillo
Hepatology
2004 ;40:793
Rx failure
HVPG and CPscore
6 week survival
22. alb
Given over 6 hours for 20% albumin and 18 hrs for HES 6%
1.5 g/kg at day 1 and 1.0 g/kg at day 3
23.
24.
25.
26.
27.
28.
29.
30. 1235 patients screened : 101 RV > 50 mmHg
MPAP > 25 mmHg in 90%
PPS observed in 55%
Remainder relate to increased MPAP in response to increased flows
Calculate transpulmonary gradient (MPAP-PAOP)
Poor correlation
with MELD
31. IAP 11.8±3.6
PDR 26.6 ± 13 vs 21.8± 7.8 (NS)
CVP 9.3±4.6 vs 15.7±4.7 (p<0.001)
Individual variation was
however observed
32. • SBP frequently associated with renal failure
• Associated with decreased effective blood volume
and high mortality
• 126 patients iv cefotaxime or iv cefotaxime plus
albumin (1.5g/kg) at day 0 and day 3 (1.0 g/kg)
• 94% and 98 % had resolution of infection
• Renal failure in 21 (33%) cef grp vs 6 (10%) in
alb/cef grp p=0.002
• Mortality 18 (29%) vs 6 (10%)
• At 3 months the mortality was 41% vs 22% p=0.03
Albumin and renal impairment in patients with
cirrhosis and SBPSort P et al N Engl J Med 1999 5; 341 (6):403
33. Haemodynamicresponse to abdominal decompression in acute
Budd^Chiari syndrome
Deepak Joshi, Sujit Saha, William Bernal, Nigel Heaton, Julia Wendon and Georg Auzinger
Institute of Liver Studies, King’sCollege Hospital, London, UK
Keywords
abdominal compartment syndrome – Budd-
Chiari syndrome – intra-abdominal
hypertension – intra-abdominal pressure
Correspondence
Dr D. Joshi Institute of Liver Studies, King’s
College Hospital, London, SE5 9RS, UK.
Tel: 1 020 3299 2504
Fax: 1 020 3299 3899
e-mail: d.joshi@nhs.net
Received 16 November 2010
Accepted 12 May 2011
DOI:10.1111/j.1478-3231.2011.02557.x
Abstract
Background: Intra-abdominal hypertension (IAH) and abdominal compart-
ment syndrome commonly occur in patients with liver disease. Aims: We
compared haemodynamic variables pre- and post-abdominal decompression
in patientswith acuteBudd–Chiari syndrome(BCS) and patientswith chronic
liver disease(CLD), ascitesand IAH. Methods: Patientswith IAH admitted to
theLiver ICU, King’sCollegeHospital werestudied. Transpulmonary thermo-
dilution cardiac output (CO) monitoring was performed with the PiCCOs
system. Results: Ten patientswith decompensated BCS(median age39 years,
20–52) and eight patients with CLD (59 years, 33–65) and tense ascites
requiring paracentesis were studied. Intra-abdominal pressure (IAP) was
raised in both groups pre-intervention (BSC 23mmHg, 17–40; CLD 26,
20–40). Intrathoracic blood volume (ITBVI) waspersistently low in the BCS
group (632ml/m2
, 453–924) despite volumeresuscitation. Post-intervention,
reduction in IAPwasnoted in both groups(BCSPo 0.001, CLD Po 0.0001).
TheITBVI increased (P= 0.001) in theBCSgroup only. An increasein cardiac
index (CI) and strokevolumeindex (SVI) wasnoted in both groups(BCS: CI
P= 0.003, SVI: P= 0.007; CLD: CI P= 0.005, SVI P= 0.02). Thecentral venous
pressuredid not changein either group and did not correlatewith markersof
flow (CI, SVI) or IAP. Both groups demonstrated an inverse relationship
between IAP, CI and SVI. Conclusion: Patients with BCS and IAH have
evidence of central hypovolaemia. In addition to raised IAP, hepatic venous
obstruction and caudatelobehypertrophy limit venousreturn in patientswith
BCS. Reduction in IAP and re-establishment of caval flow restores preload
with improvement in CO.
Intra-abdominal hypertension (IAH), (sustained elevation
of intra-abdominal pressure, IAP, Z 12mmHg) and ab-
dominal compartment syndrome(ACS) (IAPZ 20mmHg
with evidence of new organ dysfunction) are associated
with decreased survival and a high prevalence of multi-
organ failurein critically ill patients(1–3). IAP isaffected
by the volume of intra-abdominal organs, presence of
spaceoccupying lesions(solid or liquid) within theabdo-
men and conditions limiting abdominal wall expansion.
ACSleft untreated can result in pulmonary, renal and liver
including the respiratory, renal, intestinal, cerebral and in
particular the cardiovascular system (8, 9), where it is
associated with a reduction in cardiac preload caused by
reduced venous return from intra-abdominal venous ca-
pacitance vessels. Studies have demonstrated that static
fillingpressuressuch ascentral venouspressure(CVP) and
pulmonary artery occlusion pressurecorrelatepoorly with
true cardiac filling (10). They may be falsely raised in
critical illness because of changes in thoraco-abdominal
compliance such as during positive pressure ventilation
Budd^Chiari syndrome
Deepak Joshi, Sujit Saha, William Bernal, Nigel Heat
Institute of Liver Studies, King’sCollege Hospital, London, UK
Keywords
abdominal compartment syndrome – Budd-
Chiari syndrome – intra-abdominal
hypertension – intra-abdominal pressure
Correspondence
Dr D. Joshi Institute of Liver Studies, King’s
College Hospital, London, SE5 9RS, UK.
Tel: 1 020 3299 2504
Fax: 1 020 3299 3899
e-mail: d.joshi@nhs.net
Received 16 November 2010
Accepted 12 May 2011
DOI:10.1111/j.1478-3231.2011.02557.x
Abstract
Background:
ment syndrom
compared hae
in patientswi
liver disease(
theLiver ICU
dilution card
system. Resul
20–52) and
requiring par
raised in bot
20–40). Intra
group (632m
reduction in I
TheITBVI in
index (CI) an
P= 0.003, SVI
pressuredid n
flow (CI, SV
between IAP,
evidence of c
obstruction a
BCS. Reducti
with improve
Intra-abdominal hypertension (IAH), (sustained elevat
of intra-abdominal pressure, IAP, Z 12mmHg) and
dominal compartment syndrome(ACS) (IAPZ 20mm
with evidence of new organ dysfunction) are associa
with decreased survival and a high prevalence of mu
organ failurein critically ill patients(1–3). IAP isaffec
by the volume of intra-abdominal organs, presence
spaceoccupying lesions(solid or liquid) within theabd
men and conditions limiting abdominal wall expansi
ACSleft untreated can result in pulmonary, renal and li
dysfunction (4–7). ACScan complicatethediseasecou
of decompensated chronic liver disease (CLD) if por
hypertension, ascites, and less frequently bleeding fro
abdominal, as well as extra abdominal organ function
Liver International (2011)
c 2011 John Wiley & SonsA/S
cirrhosis
Budd chiari