Functions
Name 4 measures of liver function
What are:
INR, glucose, albumin, ammonia?
Name the 4 diagnostic criteria for fulminant hepatic failure
What are:
Encephalopathy
Coagulopathy
Jaundice to encephalopathy in < 8 weeks
No pre-existing liver disease (exceptions include autoimmune hepatitis and Wilson's disease)
Now that the patient has been diagnosed with fulminant hepatic failure, has been listed for transplant, these are the complications that must be managed by the ICU to reduce the risk of mortality
What are:
Encephalopathy
Cerebral edema/Intracranial hypertension
Coagulopathy/bleeding
Infection
Renal failure
Circulatory collapse
Mechanisms by which lactulose reduces ammonia
What are:
Catharsis
Acidification
Name 2 causes for altered mental status
What are:
Hyperammonemia
Hypoglycemia
Name at least 3 treatable causes of acute liver failure
What are:
Acetaminophen toxicity
Amanita phalloides toxicity
Autoimmune hepatitis
Viral hepatitis (B, C, HSV)
Wilson's disease
The major cause of mortality in fulminant hepatic failure that is the most critical to identify and manage
What is cerebral edema?
The patient has serial labs done Q4hrs and INR has risen from 3.5 to 6.5 over the past 24 hours. Under these circumstances, she should receive these products.
What are:
Correction for procedures and active bleeding
FFP
Cryoprecipitate
Novo-7
The ways in which to determine whether this patient's coagulopathy is due to liver failure versus from other causes such as DIC
What is:
Response to vitamin K
Measurement of vitamin K dependent factors
Based on the presentation and lab values, the prognosis and need for transplant can be determined by these criteria.
What are the King's College criteria
INR >6.5
Any of the 3
Age <10
Etiology: non-A/non-B hepatitis, drug-induced
Duration of jaundice to encephalopathy >7 days
INR >3.5
Serum bilirubin >300 micromol/L (17.5mg/dL)
INR at which spontaneous bleeding may occur
What is 8?
The conditions in which intubation of this patient is mandatory.
What is stage III encephalopathy?
The dysfunction of the liver that leads to encephalopathy.
The patient is evaluated for liver transplant, name 3 of the 5 components included in PELD score calculation
What are bilirubin, INR, albumin, growth, and age?
PELDScore = 10 * ((0.480 * ln(Bilirubin)) + (1.857 * ln(INR)) - (0.687 * ln(Albumin)) + Listing Age Factor + Growth Failure Factor)
Complications that would preclude candidacy for transplant
What are:
Sepsis
Herniation
The patient has been afebrile but should receive antibiotics under these circumstances.
What are:
High-grade (III, IV) encephalopathy
Refractory hypotension
Renal failure
Systemic inflammatory response syndrome
The goal ICP to be under and CPP to be over to avoid hypo perfusion of the brain
What are:
ICP <20mm hg
CPP >60 mmHg
The patient has developed asterixis in addition to increased drowsiness which would be characterized as this stage of encephalopathy
What is stage II encephalopathy?
In comparison to a baby with h/o biliary atresia and cirrhosis, the reason why this patient is at higher risk of developing cerebral edema from hyperammonemia
What is the export of compensatory organic osmolytes?
The use of this agent has been shown to have no impact on overall survival and has been shown to decrease 1 year transplant-free survival
What is NAC?