BCC4: Clive Woolfe on Chronic Liver Disease

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Clive Woolfe, Irishman and RPA Intensivist, speaks at Bedside Critical Care Conference. In this podcast, he gives an overview of the prognostication and management of chronic liver disease. See www.intensivecarenetwork.com for the podcast.

Salud y medicina

Chronic Liver Disease
BCC, Cairns, September 2013

Clive Woolfe

Cirrhosis “late stage of progressive hepatic ﬁbrosis”
Death from Portal Hypertension,
progressive MOF, not encephalopathy

The economic cost and health
burden of liver disease in Australia
January 2013

Child-Turcotte-Pugh
Abdominal Surgery
Mortality (%)
!
10
!
30
!
82

MELD
Model for Endstage Liver Disease
9.57 x ln(Creatinine) + 3.78 x ln(Bilirubin) +11.2 x In(INR) + 6.43

MELD
Model for Endstage Liver Disease
9.57 x ln(Creatinine) + 3.78 x ln(Bilirubin) +11.2 x In(INR) + 6.43
20
40
60
80
100
0 10 15 20 25 30 40
83
80 78
74
71
90
81
63
42
21
Waiting List Survival
1 year post OLTx Survival
MELD Score
%

ICU
Reversible precipitant?
!
Organ support as a bridge
to transplant

Precipitants
Look for Reversibility
Drugs
BDZ

Narcotics
Ammonia
Diet

Infection

GI bleeding

Hypokalaemia
Constipation

Metab Alkalosis Vascular Occlusion

Porto-systemic shunts
NH3
Dehydration
VD

Hemorrhage

Diuretics

Paracentesis
HCC
Alcohol

Variceal Haemorrhage
Median Follow Up 2.5 years

No survival
advantage

2x Encephalopathy
?

Neurological
NH3
Serial Examination
Hippus

Clonus

Hyperreﬂexia

Respiratory
Bleeding

Sepsis
?Hepato-pulmonary Syndrome
Porto-Pulmonary Hypertension
PAP
Massive TidalVolumes
Paracentesi

Renal/Fluids
Renal hypoperfusion

RAA activation
Low
Intravascular
Volume vs.

High TBW
Hepatic

CongestionHepatorenal

Syndrome
Late presentation:

Low muscle mass

Low urea production
“Euvolaemia”

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