November 27, 2019

REBEL Core Cast 22.0 – Decompensated Liver Disease

Take Home Points   

  • End stage liver disease patients have fragile baseline physiology. Minor insults can have profound effects
  • Always start with the basics – large bore IV lines
  • SBP give 3rd generation cephalosporin + albumin in severe disease
  • Upper GI bleed give appropriate blood products + ceftriaxone

 

REBEL Core Cast 22.0 – Decompensated Liver Disease

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What does the liver do

  • Makes most of macrophages and complement proteins
  • Produces clotting factors and fibrinogen and Protein C & S and antithrombin
  • Produces albumin – creates oncotic gradient

Cirrhosis

  • Represents a late stage of progressive hepatic fibrosis characterized by distortion of the hepatic architecture
  • Essential functions of liver compromised – immunocompromised, vasodilated, hyperdynamic cardiac function at baseline. Not healthy patients!!

Things to consider in presentation of cirrhotic patients

  • Consider them all immunocompromised!
    • May lack fever, leukocytosis on presentation – presume they’re all sick
  • Ask yourself why they’re coming in
    • Increasing ascites – why is it getting bigger?
    • Hepatic encephalopathy – don’t just treat elevated ammonia, ask why it’s happening
  • Calculate Shock Index – HR / SBP
    • > 0.7 – abnormal
    • > 1.0 – worrisome
    • Can clue you into patient being hypovolemic before they become hypotensive.
    • Note: Many patients are on beta blockers which can mask tachycardia

Access

  • These patients can be tough vascular access
  • Central line is not your best bet, get short, fat catheters for great flow rates.
  • If you can’t get IV access, get an IO in there

Spontaneous bacterial peritonitis

  • Suspect in all patients with ascites
  • Classic triad of fever, ascites and abdominal pain is rarely present
  • New renal failure, diarrhea, hypothermia and acidosis are potential presentations
  • 13% will present with no symptoms at all!!
  • Have a low threshold to tap
    • >250 PMN is main diagnostic criteria, also send for cultures
  • Management
    • 3rd generation cephalosporin (ceftriaxone or cefotaxime)
      • Ceftriaxone 25 mg/kg up to 2 gm daily
      • Cefotaxime 25 mg/kg up to 1 gm Q8
    • 1.5g/kg of albumin
      • Benefit of albumin is in patient with severe disease with creatinine >1, BUN > 30 or total bili > 4
    • Albumin + Antibiotic had 20% reduction in renal failure and a 25% reduction in mortality

GI Bleed

  • Cirrhotic patients develop varices at rate of 5-15% per year
  • Management
    • 2 Large Bore IVs
    • Emergency Type O from the beginning
      • Call for 4 Units immediately then switch to type specific
      • Consider massive transfusion protocol
      • O negative for women of child bearing age, O positive for all others
  • Send off TEG to help guide resuscitation
  • If no TEG, send Fibrinogen level
    • Fibrinogen <100:  give cryoprecipitate
  • Secure airway – consider delayed sequence intubation
    • Delayed sequence will allow you to preoxygenate, suction and drop NG tube to decompress GI tract
    • Ketamine 0.5 mg/kg IV
  • Get Blakemore or Minnesota tube ready
  • Octreotide and PPI do not affect these patients mortality
  • Give antibiotic!
    • Ceftriaxone or other 3rd generation cephalosporin
    • NNT of 4 for preventing infection
    • NNT of 22 for reducing mortality

Links & Resources:

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Anand Swaminathan, "REBEL Core Cast 22.0 – Decompensated Liver Disease", REBEL EM blog, November 27, 2019. Available at: https://rebelem.com/rebel-core-cast-22-0-decompensated-liver-disease/.
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Anand Swaminathan

Clinical Assistant Professor of Emergency Medicine at St. Joe's Regional Medical Center (Paterson, NJ)
REBEL EM Associate Editor and Author
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