End Stage Liver Disease
Considerations
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Airway:
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Aspiration risk due to ↑ gastric volume
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Friable/edematous tissues
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Multiorgan dysfunction:
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CNS: encephalopathy
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Cardiovascular: hyperdynamic circulation (↑ cardiac output, ↓ SVR), cardiomyopathy, portopulmonary HTN
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Pulmonary: hypoxemia (intrapulmonary AV shunting, V/Q mismatch); restrictive lung physiology (ascites & pleural effusions)
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GU: hepatorenal syndrome/renal failure
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GI: U/LGIB from varices & AVM’s
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Hematology: coagulopathy (↓ platelets, ↓ clotting factors, ↑ fibrinolysis) & immunodeficiency
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Endocrine: hypoglycemia, hyponatremia, lactic acidosis
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Etiology/associated conditions:
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Viral (e.g. hepatitis)
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Drugs (e.g. alcohol, acetaminophen)
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Autoimmune (α-1-antitrypsin deficiency)
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Hemochromatosis
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Altered drug pharmacology (↑ volume of distribution, ↓ hepatic clearance, ↓ protein binding)
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Altered fluid physiology:
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Total body water excess (ascites) with intravascular volume depletion
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Low albumin state
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Reconsider elective surgery in very high risk patients (child-pugh class C or MELD > 20)
Goals
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Identify & optimize multisystem complications
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Avoid elective or non-emergent surgery in acute liver dysfunction
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Pre-operative correction of coagulopathy & hypovolemia
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Consider draining ascites to optimize respiratory mechanics
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Anticipate fluid shifts & major blood loss
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Appropriate use of hepatically-metabolized drugs
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Universal precautions to prevent viral transmission
Conflicts
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Need for regional vs. coagulopathy
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High risk patients vs. elective surgery
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Pulmonary hypertension vs. laparoscopy
Massive Variceal Bleed
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Emergency situation
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Needs emergent airway management with RSI, 2 suctions
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Massive hemorrhage: give blood products as indicated, reverse coagulopathy, call massive tranfusion protocol
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Pharmacologic:
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Vasopressin 0.4 unit bolus followed by an infusion of 0.4 to 1 units/min
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Ocreotide: 50 mcg bolus, then 50 mcg/hr infusion
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Balloon tamponade: blakemore (minnesota) tube
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Endoscopic management of varices
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TIPS if endoscopic management fails