【持续性肾脏替代治疗crrt英文精品课件】acute liver failure (alf)

Acute liver failure (ALF),Bengt-ke Henriksson CIVA SU/S Gteborg,William Bernal Liver Intensive Care Unit Kings College Hospital London,Acute vs Chronic liver failure,Encephalopathy /progressive vs fluctuating/ Cerebral oedema /yes vs no/,Case 1,42 year old woman Analgetics due to a Whiplash injury An earlier suicide attempt,Case 1 cont.,Ambulance record Unconscious lying on the floor Cold and pale. Spontaneous breathing RLS 4 SAP 80 mmHg Transferred to hospital,Case 1 cont.,ICU Spontaneous breathing Hypoxia X-ray normal Hypotension RLS 4 Oliguria,Treatment Intubation Colloids, Crystalloids Inotropic support,First 24 hours in hospital,Case 1 cont.,Laboratory ASAT 290 kat/l ALAT 190 kat/l Bil 41 mol/l Amylase 29.2 kat/l PK(INR) 3.4 pH 6.97, BE -27,Laboratory Paracetamol/se 750 mmol/l Myoglobin/se 86600 g/l,Case 1 cont.,ICU Spontaneous breathing Hypoxia X-ray normal Hypotension RLS 4-5 Anuria CT brain normal,Treatment Intubation Colloids, Crystalloids Inotropic support Mannitol, Furosemid Antibiotics Acetylcysteine,First 24 hours in hospital,Case 1 cont. - SU/S,Ventilator 100% O2 Pulmonary oedema Hypotension, CO 7-8 l/min Normal pupils but dilate after some hours RLS 7-8 Anuric PK(INR) 5,2,Urgent call for LTx,Need for ICU,RLS2,Team work,Intensive care,Support vital functions Avoid complications Identify patients with a bad prognosis Optimal conditions for liver regeneration Optimal conditions for transplantation,Acute liver failure!,Support CNS Respiration Circulation CRRT/MARS Coagulation Infection Metabolism,CNS,Control of ICP ICP monitoring PK(INR) 50 x 109 /l RLS 4 or sedated patient on ventilator ICP 50-60 mmHg EEG monitoring Sedated patient on ventilator,Respiration,Intubate before transport to transplantation centre Avoid high PEEP,Circulation,Optimise blood volume Optimise vascular tone Cardiac support Steroids,CRRT/MARS,Early CRRT Reduce oedema High ICP Ultrafiltration MARS?,Coagulation,When bleeding Plasma, Thrombocytes, Fibrinogen, NovoSeven Specific treatment In desperate situations Plasmapheresis,Infection,SIRS due to FHF Sepsis Prophylaxis Bacteria Fungi,Daily cultures,Metabolism,Hypoglycemia Hyperlactatemia Metabolic alkalosis,Hepatectomy?,Daily laboratory tests,Phosphate/se Amylase/se Lactate/se TEG Indocyanine elimination Daily cultures,Medical treatment,Acetylcystein Konakion Pantoloc Meronem Ambisome/Diflucan ProEpanutin,Case 1 cont. - SU/S,Ventilator 100% O2 Pulmonary oedema Hypotension, CO 7-8 l/min Normal pupils but dilate after some hours Anuric PK(INR) 5,2,Norepinephrine, Dobutamine CRRT Barbiturates Intracranial pressure monitoring device not available Antibiotics,Case 1; Laboratory data,Case 2 19/9,24 year old soldier The night before abdominal discomfort Collapsed during a cross-country race Found unconscious with convulsions,Case 2 cont. 19/9,Emergency department Temperature 41.7 C Unconscious Pupils dilated Hyperventilation (40 /min) Heart rate 180/min,Diagnosis Heat stroke,Case 2 cont. 21/9,Septicemia Staphylococcus aureus Metabolic acidosis Lactate 18.5 mmol/l Creatinine 421 mol/l ALAT 234 kat/l Bil 106 mol/l APTT 66s PK(INR) 3.5 Thrombocytes 29 x 109 /l,Treatment Intubation and on ventilator Midazolam Inotropic support Acetylcysteine Antibiotics CRRT,Case 2 cont. 25/9,Transferred to SU/S Comatous, RLS 7-8 PEARRL On ventilator FiO2 0.35 No inotropic support Low urine output PRISMA/MARS CT-scan normal,Laboratory ASAT 12 kat/l ALAT 14 kat/l Bil 300 mol/l PK(INR) 3.4 Fibrinogen 1.4 g/l Lactate 3 mmol/l,Case 2 cont. 29/9,Bleeding from right lung,Treatment Plasma Fibrinogen Surgical tracheostomy Bleeding from tracheostoma,Normal coagulation,TF-Bearing Cell,Activated Platelet,Platelet,TF,TF,VIIa,Xa,X,II,IIa,V,Va,II,X,IIa,Xa,Va,IX,Va,VIIa,IXa,VIIIa,VIII/vWF,VIIIa,Fibrinogen,Fibrin,XIIIa,Fibrin,NovoSeven,Activated Platelet,Platelet,TF,TF,Xa,X,II,IIa,V,Va,II,X,IIa,Xa,Va