Acute LiverFailure
Clinical Case Scenario
• 36-year old patient with known alcoholic hepatic
cirrhosis, was repetetively admitted to the
hospital due to acute decompensation during the
last several months.
• Now the emergency service is called because of
loss of consciousness and seizures of his right
arm and leg.
• On the scene, diazepam 15 mg i.v. is applied but
the seizures do not subside, afterwards he is
sedated with propofol and intubated.
• He is brought to the ER of University hospital on
mechanical ventilation, sedated,
hemodynamically stabilized.
• Urea 2.6 mmol/l
• Creat. 49 umol/l
• Na 133 mmol/l
• K 3.8 mmol/l
• Cl 105 mmol/l
• Ca 1.92 mmol/l
• P 0.96 mmol/l
• Mg 0.48 mmol/l
• Bi-tot. 90 umol/l
• ALT 0.25 ukat/l
• AST 0.71 ukat/l
• GGT 1.09 ukat/l
• ALP 0.73 ukat/l
• Blood proteins 53.8 g/l
• Albumin 21.6 g/l
• Glucose 5.9 mmol/l
• Triglycerides 0.9 g/l
• CRP 37.3 mg/l
• Procalc. 0.4 ng/ml
• Ammonium 88 umol/l
• Lactate 1.6 mmol/l
• B(a)pH 7.36
• B(a)pCO2 5
• B(a)pO2 16
• B(a)HCO3 20.8
• B(a)BD- -4
• Leukocytes 1.17
• Erythrocytes 2.16
• Hemoglobin 75.2
• Hematocrit 0.21
• MCV 98.4
• Platelets 40.2
• Cencetration of HGB 354
• Prothrombin time INR 1.76
• Prothrombin time s 22.1
• Prothrombin time R 1.58
• Fibrinogen g/l 1.95
• aPTT -ratio 1.4
• aPTT s 46.2
Child-Pugh Score
Acute liver failure
• Liver has many functions, central role in metabolism
• Acute failure – up till 6 months from the beginning of signs
and symptoms
• Coagulopathy and/or encephalopathy within 6 months of
icterus = jaundice
• Up till 7 days – fulminant hepatic failure
• From 7 – 28 days – acute hepatic failure
• From 4 – 12 weeks – subacute hepatic failure
Acute hepatic failure - causes
• Viral hepatitis – A-E, HSV...
• Drug-induced – paracetamol...
• Toxins – mushrooms, tetrachlormethane...
• Vascular accidents – portal trombosis, BuddChiari
syndrome...
• Pregnancy-associated – HELLP...
• Others – trauma, Wilson´s disease, alcohol
abuse
Acute on Chronic liver failure
• Compensated liver cirrhosis
• Intercurrent infection or bleeding
• SIRS criteria have limited value !
• Spont. bacterial peritonitis, pneumonia,
urinary tract infection...
• Bleeding from oesophageal varices
Hepatic Encephalopathy
• Elevated levels of ammonia
Hepatic failure - therapy
• Therapy of the cause of AHF – virostatics,
acetylcysteine
• Organ support – artificial ventilation,
vasopressors ± inotropics, elimination
methods, blood products
• Encephalopathy – non-resorbable antibiotics
(rifaximine), lactulose, therapy of intracranial
hypertension
• GIT detoxication was initiated, vitamin K and
thiamin were supplemented. Terlipressin was
given because of oliguria.
• Suspicion on spontaneous bacterial peritonitis
was stated, cefotaxim was administered
empirically.
Ascites analysis
• Leukocytes - 10^9/l 0.3
• Erythrocytes - 10^12 0.01
• Hemoglobin g/l 0.93
• Platelets 10^9/l 0.52
• Neutrophils % 40
• Lymfocytes % 32.5
• Monocytes % 12
• Eozinophils % 15.5
• Bazophils % 0
• Neutrophils x10 9 0.12 (<0.25)
• Sedation was stopped, organ function were
stable. No epileptogenic activity was detected by
EEG. After 24 hrs he was disconnected from the
ventilator and extubated.
• During the next 2 days respiratory failure
reappeared and the patient was reintubated.
Temporarily aggressive mechanical ventilation
due to alveolar lung oedema was needed. After
diuretic therapy oxygenation improved, sedation
was stopped with patient regaining consiousness.
• On day 4, the patient is agitated, tachycardic,
hypertensive, tachypneic.
• Laboratory results including ammonia level are
normal.
Delirium
• Syndrome present during various diseases
(metabolic, intoxications, withdrawal
syndrome, sepsis…) caused by disturbance of
normal functioning of brain.
• Cca 1/3 – 1/2 of patients hospitalized in ICUs.
• Changes of consciousness - qualitative
(hallucinations, desorientation) and
quantitative (hyper- or hypoactive).
Delirium - therapy
• Correction of the underlying pathology.
• Supportive measures – nutrition, adequate analgesia…
• Repeated reassuring, reorientation, explanation.
• Night x day rhythm restoration – quiet environment.
• Early mobilisation, rehabilitation, vertical position.
• Medication – quetiapin, haloperidol, dexmedetomidine – no
benefit for delirium itself, treats agitation only.
• After another 7 days and successful weaning
the patient was finally extubated.
Orthotopic Hepatic Transplantation
• King´s college criteria
Bridging therapy – detoxifying systems
(Prometheus, MARS = Molecular
Adsorbents Recirculation System)