i have no financial relationship(s) to disclose relevant to my presentation
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All Fluids are bad The Liver and abdominal hypertension Julia Wendon Consultant Intensivist and Hepatologist Institute of Liver Studies Kings College Hospital London. I have no financial relationship(s) to disclose relevant to my presentation. [email protected]. - PowerPoint PPT PresentationTRANSCRIPT
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I have no financial relationship(s) to disclose relevant to my presentation.
All Fluids are bad The Liver and abdominal hypertension
Julia WendonConsultant Intensivist and Hepatologist
Institute of Liver Studies Kings College Hospital
London
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A bit is good – too much – well
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Potential Categorization of liver dysfunction in critical care /MOF
Primary liver InjuryAcute
Acute liver Injury
Acute Liver failure
Chronic
Decompensated CLD
Critically ill cirrhotics
Surgical
Hepatectomy
Trauma
Iatrogenic
Secondary liver Injury Sepsis / inflammation
Ischemia/Congestion
Systemic disease
DrugsTPNOther…..
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Fluids and liver disease
• 5% dextrose • 20-50% dextrose • N/ Saline / Hartmans / balanced crystalloids
• Colloids • 4.5% albumin 20% albumin • gelatins , starch
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Haemodynamics and issues • ALF
– Initially all volume deplete – difficult to say fluid is bad
– Risk of pancreatitis, gut oedema – Stiff liver, develop ascites easily
• Hepatic resection – Initially usually run dry – Risk of small for size syndrome – Portal inflow excessive to outflow– Adequate but not excess fluid required
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Haemodynamics of cirrhosis • Group 1
– Ascites, central hyovolaemia, total blood volume increased, usually diuresed ++ and low na and poor kidneys
• Group 2– RV volume / pressure overload, ascites and oedema,
cirrhotic cardiomyopathy, No PHT, usually high CI TPG• Group 3
– Portopulmonary syndrome with normal RA, initially maintained CI
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Situations for discussion • Acute liver failure
– Plasma exchange
• Ascites and drainage of said • Variceal haemorrhage • Hepatorenal failure
• Continuity between right heart, hepatic veins, liver and sinusoids and back to portal vein and hence guts – gut oedema, translocation
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IAP
CVPPcwP
PeeP
Compliance ↓
Echo findings also predictive of mortality post TIPS
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IAP and fluid responsiveness
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Problems related to hypotonic solutions
Replace with albumin 20% to prevent PICDAlso consider risk of variceal bleeding
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Consider IAP and renal perfusion pressure Options 1. Decrease IAP 2. Increase RPP 3. Improve central blood volume
RPP 61 to 67 mmHg
Potential risk of variceal bleed ???
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Pre paracentesis4-10 L +ive Pressors 0.45 µg/kg/min9 L ascitesDrained
Replaced 20% Albumin 1.2 L
PLR : no increase
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Terlipressin ± albumin Ortega et al Hepatology 2002;36:941
0.5 mg 4 hrly , albumin 1g/kg/body weight day 1 then 20 - 40 g/day
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Sanyal A Gatroenterology 2008 :134:1360
Albumin daily 1g/kg
Martin-Llahi M Gastroenterology 2008:134
Data also for norepinephrine and Ptx and NAC
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10 trials only type I and II Drug ± alb vs no intervention
Vasoconstrictors + Alb : Effect on mortality at 15 days but not at 30, 90 or 180 days RR 0.6 (0.37-0.97)
Terlipressin + Albumin vs Albumin : decreased mortality in type IRR 0.83 (0.65-1.05)
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MAP no relationship to changes in GFRMAP increased (>85)Reversal of RAA, NE levels
Creatinine is Dreadful measure Of renal function
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Airway Breathing Circulation
fluids - coagulation factors ??
others ?Na issues IAP – ascites &
endoscopyTerlipressin / somatostatin
Watch right sided pressures
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• 116 patients with cirrhosis and variceal bleed• Endoscopy and sclerotherapy• HVPG measured within first 24 hours: < or > 20
mmHg• If > 20 randomized to TIPS or medical Rx
Monescillo Hepatology 2004 ;40:793
Rx failureHVPG and CPscore
6 week survival
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alb
Given over 6 hours for 20% albumin and 18 hrs for HES 6%1.5 g/kg at day 1 and 1.0 g/kg at day 3
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1235 patients screened : 101 RV > 50 mmHgMPAP > 25 mmHg in 90%
PPS observed in 55%Remainder relate to increased MPAP in response to increased flowsCalculate transpulmonary gradient (MPAP-PAOP)
Poor correlation with MELD
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IAP 11.8±3.6
PDR 26.6 ± 13 vs 21.8± 7.8 (NS)
CVP 9.3±4.6 vs 15.7±4.7 (p<0.001)
Individual variation was however observed
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• SBP frequently associated with renal failure• Associated with decreased effective blood volume
and high mortality• 126 patients iv cefotaxime or iv cefotaxime plus
albumin (1.5g/kg) at day 0 and day 3 (1.0 g/kg)• 94% and 98 % had resolution of infection• Renal failure in 21 (33%) cef grp vs 6 (10%) in alb/cef
grp p=0.002• Mortality 18 (29%) vs 6 (10%) • At 3 months the mortality was 41% vs 22% p=0.03
Albumin and renal impairment in patients with cirrhosis and SBP Sort P et al N Engl J Med 1999 5; 341 (6):403
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cirrhosis
Budd chiari