BCC4: Clive Woolfe on Chronic Liver Disease
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Chronic Liver Disease BCC, Cairns, September 2013 Clive Woolfe
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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 www.intensivecarenetwork.com for the podcast.
Transcript of BCC4: Clive Woolfe on Chronic Liver Disease
Chronic Liver DiseaseBCC, Cairns, September 2013
Clive Woolfe
Definitions
Organ����������� ������������������ SupportPrognositicating...
Facts����������� ������������������ and����������� ������������������ Figures
Cirrhosis “late stage of progressive hepatic fibrosis”
Death from Portal Hypertension, progressive MOF, not encephalopathy
The economic cost and health burden of liver disease in Australia
January 2013
Child-Turcotte-Pugh
Abdominal Surgery Mortality (%)
!10 !
30 !
82
MELD Model for Endstage Liver Disease
9.57 x ln(Creatinine) + 3.78 x ln(Bilirubin) +11.2 x In(INR) + 6.43
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
8380 78
7471
90
81
63
42
21
Waiting List Survival1 year post OLTx Survival
MELD Score
%
Terminal Disease... progressive MOF
ICU
ICU
Reversible precipitant? !
Organ support as a bridge to transplant
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
Variceal Haemorrhage
Median Follow Up 2.5 years
No survival advantage
2x Encephalopathy?
Organ support
Neurological
NH3
Serial Examination Hippus Clonus
Hyperreflexia
Efficacy of “Treatments” for HE
+
Respiratory
Bleeding Sepsis
?Hepato-pulmonary Syndrome
Porto-Pulmonary Hypertension
PAP
Massive Tidal Volumes
Paracentesi
CVS
E. Coli
Renal/FluidsRenal hypoperfusion
RAA activationLow
Intravascular Volume vs. High TBW
Hepatic CongestionHepatorenal
Syndrome
Late presentation: Low muscle mass
Low urea production
“Euvolaemia”
Gastrointestinal
Precipitating Event
SBP
Prophylaxis
Sepsis !
24% of cirrhotic inpatients RTI > UTI > C.Diff
Mortality increase: 39 to 49%
Finally...
ICU
Reversible precipitant? !
Organ support as a bridge to transplant
ICU
Reversible precipitant? !
Organ support as a bridge to transplant
