Acute on Chronic Liver Failure

Published 29/08/2024

Acute on Chronic Liver Failure

Set-up: 

Intensive Care Unit 

Lines/access: 

2 x pink peripheral venous cannulae, 1 x Rt IJV CVC 

Infusions: 

Hartmanns running, 250mL STAT 

Airway: 

SV 

Ventilator: 

Nil 

Other: 

Drug chart from previous hospital, ICU drug chart 

Patient’s notes, bloods, VBG x 2, CXR x1, ECG x2 

Previous OGD report, CIWA chart 

Clinical setting

I: You are the ICU Registrar and are asked to see a hypotensive patient who has arrived earlier from another hospital  

S: Transferred from a DGH following admission with symptoms of upper GI bleed. OGD: Grade 3 oesophageal varices found, 6 varices banded. Further bleeding so transferred for assessment for TIPSS, currently NBM 

B: 35M, BG alcohol related liver disease 

A:  Patient remains hypotensive despite 3L crystalloid and colloid resuscitation during transfer. Is on terlipressin. 

R: Asked to review patient 

Potential Clinical Course

  • Features of chronic liver disease present on assessment.

  • Patient hypotensive and hyperdynamic in context of acute decompensation. 

  • No further evidence of bleeding, no haematemesis and no melaena, no Hb drop on blood gas. 

  • Confused, not able to assess for liver flap, has grade III encephalopathy, last CIWA score 4. 

 

  • Blood pressure responds transiently to fluid bolus if given up to 99/52, but drops again to 89/43 shortly after. 

  • If repeated fluid boluses are given, patient desaturates and develops oxygen requirement.  

  • Blood pressure responds well to commencing noradrenaline via CVC, MAP >65 achieved with norad 0.1mcg/kg/min. 

  • Patient is snoring, rousable but very drowsy and very incoherent in speech. No suggested interventions improve this. 

Key steps

  • Volume replacement with colloid (blood/albumin) but recognition for need for pressors as no sustained improvement, aiming MAP >65 and Hb >70.

  • Recognition of need for intubation and neuroprotective measures to manage encephalopathy.  

  • Consideration of correction of clotting with vitamin K 10mg OD IV for three days and consider TEG (if available). 

  • Sends ammonia and considers ammonia lowering therapies and whether patient may require haemofiltration. 

  • Consider baseline CT Head after intubation. 

  • Liaises with hepatology team re: next steps and assessment for TIPSS. 

  • Ascitic Tap to rule of SBP as cause for decompensation. 

Info Sheet For Faculty

Observations:

  • On arrival, patient SV 

  • RR 16, sats 97% on 2L via NC 

  • BP 92/43, HR 115 sinus tachycardia  

  • Grade III encephalopathy, PEARL, T35.5, BM 3.1 

  • Jaundiced, abdomen distended, caput medusae on the abdomen, non-tender. Calves soft, some bruising to the lower and upper limbs, spider naevi on the chest, peripherally oedematous (low albumin) 

  • FB currently +3L, UO 10/15/10, Cr 187 (baseline 110), Ur 22 

  • Patient NBM, no further episodes of haematemesis or malaena  

  • Hb74, Plt 52, INR 2.6, no anticoagulants or anti-platelets 

  • On piperacillin/tazobactam from referring hospital 

Faculty Roles

Bedside Nurse 1:  

  • You are a senior and experienced ITU nurse 

  • You are concerned that this patient remains hypotensive despite two fluid boluses since his transfer 

  • On arrival, the blood pressure was 120/56, but this has subsequently dropped 

  • You are helpful and efficient in completing tasks 

  • You offer suggestions when the candidate is unsure 

  • You have a trolley prepared with intubation equipment and the drugs required which are already drawn and labelled. 

 

Hepatology/Gastroenterology SpR (over phone): 

  • You are not immediately available to attend but agree to prioritise this patient 

  • You provide helpful advice over the phone 

 

HiLLO: 1, 2, 4, 5, 6 

Acute on Chronic Liver Failure
Download