Acute Liver Failure filletofish.net.pptx

acuteliverfailure commoncauses managementjos l gonz lez r3johna donovan md whyacuteliverfailure whydidichoosethistopicandwhyisitimportantforclinicians identificationofalfregenerativepropertiesinterventionslivertransplant presentationoutline introductionacetaminophentoxicityidiosyncraticdrugreactionsviralhepatitiscomplicationsandmanagementlivertransplant conclusionn acetylcysteinefornon acetaminophencausesofacuteliverfailurebydr donovan learningobjectives recognizeacuteliverfailureunderstandacetaminophentoxicity applyappropriatetreatmentunderstandcommoncausesofviralalfandidentifytheinterventionsthatimproveoutcomesknowwhichgroupsofdrugscommonlycauseliverinjuryidentifyprognosticcriteriamanagecomplicationsofalf definingacuteliverfailure inr 1 5alteredmentalstatusillnessof21daysand 26weeksfulminant 2wks vssubfulminant 2 12wks whatarethecommoncausesofliverfailure acetaminophen39 indeterminite17 idiosynchraticdrugrxns13 viralhepatitis12 hbv hav hev hsv autoimmune4 5 wilson sdisease2 3 mushroompoisoningherbalmedicationsvascularbud chiarriischemichepaticveinthrombosisreye ssyndromefattyliverofpregnancyhellp acetaminophentoxicity para acetylaminophenol treatmentnomogram acetaminophentoxicity treatment gidecontamination activatedcharcoaln acetylcysteine20hourivprotocol72hourpoprotocollivertransplant indicationsforlivertransplant king scollegecriteriaforacetaminophentoxicity arterialph100secandcr 3 3 idiosyncraticdrugreactions idiosyncraticdrugreactions idiosyncratic unpredictableanddose independentpatternofinjuryvariescholestatic alkalinephosphotase hepatocellular alt mixedmechanismofactioncovalentbonds disruptionofcellmembraneinhibitionofcellularpathwaysabnormalbileflowpumpdysfunctionapoptosisviatnfandfaspathwaysinhibitionofmitochondrialsynthesis idiosyncraticdrugreactions moa 1antimicrobials 2cnsagents 3herbalsupplements weightloss musclebuilding idiosyncraticdrugreactions whatfactorsinfluencesusceptibility 40yoa obesity femalegender dm etohuse geneticvariabilityimportanceofdiscontinuingmedicationafterliverinjury likelihoodofprogressiontoliverfailureisdependentonhowlongyoucontinuetotakethedrugafteridentificationofliverinjury whatistheclinicalcourseandnaturalhistoryofdisease repairvaries daystoweekstomonths viralcausesofacuteliverfailure viralcausesofacuteliverfailure hepatitisb 8 hepatitisdhepatitisa 4 hepatitisc doesnotcausealfhepatitise indevelopingcountrieshsv ebv acutehepatitisbleadingtoalf hbv dnavirusantivirals nucleosideornucleotideanalogslamivudine adefovir tenofovir entecavirlamivudinetreatmentimprovestheprognosisoffulminanthepatitisb serologiesforacutehepb igmanti hepatitisbviruscoreantibodyretrospectivecohortstudy n 3310patientsreceivedlamivudineendpoints 1week overallsurvival1wk 90 vs65 overall 70 vs26 lamivudinetreatmentimprovestheprognosisoffulminanthepatitisb acutehepatitisb factorsassociatedwithincreasedmortality acuteliverfailure managementandprognosis whatarethepotentialoutcomes 1 recoverybecauseofasuccessfulinterventionnacforacetaminophentoxicityantiviralsforacutehepatitisb2 spontaneousrecoverywithsupportivecare3 death4 rescuebylivertransplant predictingoutcomesinacuteliferfailure mostimportantpredictivefactors degreeofencephalopathysuggestedlaboratorymarkers factorvafpserumphosphatevii vratio 30gcglobulinclinicalalgorithms king scollegecriteriaapacheii king scollegecriteria non acetaminophen inr 6 5orany3ofthefollowing5 age40serumbilirubin 18jaundicetoencephalopathyinterval 7daysinr 3 5unfavorableetiologynon a non bhepatitis halothane idiosyncraticdrugreaction wilson s apacheiiscoringtable predictingoutcomes whichvariableorclinicalalgorithmdoweuse meta analysisofprognosticcriterianoprospectivetrialsasofyetwhyissensitivityimportant falsenegatives deathduetowithholdinglivertransplantswhyisspecificityimportant falsepositives livertransplantsinthosethatdon tneedthem meta analysisofprognosticcriteria needfortransplant reviewedrawdataarterialph pt cr factorv gc globulinking scollegecriteria apacheiiscoreprospectivestudyneeded commoncomplicationsofacuteliverfailure clinicalcourseandmanagement complicationsofacuteliverfailure cnsdisturbanceshepaticencephalopathycerebraledemahemodynamiccollapseinfectionscoagulopathyandbleedingrenalfailuremetabolicderangements cerebraledema astrocytes nh3 glutamine edemadegreeofencephalopathycorrelatesw cerebraledemagradei ii 25 35 riskgradeiii 65 riskgradeiv 75 riskuncalherniationcompromisescerebralbloodflow hypoxicbraininjury intracranialpressure cpp map icpcpp 60mmhgicp 20mmhg intracranialpressure cpp map icpcpp 60mmhgicp 20mmhg treatmentsforraisedicp howusefularethey hob 30 decreasedpatientstimulationhyperventilationbarbituratesmannitolcorticosteroidshypertonicsalinehypothermia 32 33 c hemodynamicfailure decreasedsvrrenalfailure pulmonaryfailureandcardiovascularcollapserestorationofhemodynamics crystalloidinitiallyonceeuvolemic studiesshowalbuminisbetterthancrystalloidpressorsalphaadrenergics epi andnorepi notused dopamine vassopressinnobenefitofnac prostaglandinsandsteroids infections etiologybacterial 90 gramnegativeorganisms staphylococcifungal 30 sirshasbeenshowntodecreasesurvivalrateshouldweuseprophylacticantibiotics decrease ofinfectionsbutnoimprovementinoutcomesroutinesurveillanceblood sputum urineculturesandcxr coagulopathy coagulopathies prolongedptplateletdysfunctionreductioninfactorsii vii ixandxdefectiveproductionofprocoagulantfactors proteinscandsantithrombiniiiupregulationoffactorviiiendresult clinicallysignificantspontaneousbleedingisrelativelyunusualinalf evenduringlivertransplant overuseofbloodproducts correctionofcoagulopathies vitaminkplateletsifclinicallysignificantbleedingor 10klimitedroleforprophylacticffp platelets cryoprecipitategivingffptakesawayyourbestprognosticindicatorrecombinantvii renalfailure rfcontributestomortalityandoverallpoorprognosismulti factorialpre renalatn fromprolongedpre renalstatevsnephrotoxicagents hrscvvd hd metabolicdisturbances lacticacidosisw compensatoryrespiratoryalkalosishypokalemiahypoglycemia 40 hypophosphatemiahypomagnasemiaearlynutritionisimportant livertransplant livertransplant indicatedwhenprognosticcriteriasuggestahighlikelihoodofdeath2004unosdata5845transplants491foracuteliverfailure 8 4 ofpatientsw alf 29 receiveatransplant survivalratesinpre transplantera 15 vs40 nowbetterprognosis acetaminophen hav ischemia aflpworseprognosis hbv aih wilson s bud chiari variationsoftransplants orthotopiclivertransplantauxiliarylivertransplantxenotransplantationartificial bioartificialhepaticassistdevicesdetoxify metabolizeandsynthesizehepatocytetransplantation summary alf inr 1 5 ams hav txw antiviralsidprognosticcriteria apacheiivsking scollege age ams etiologymanagecomplications increasedicp hemodynamicinstability rf coagulopathies metabolicderrangements americanassociationforthestudyofliverdiseaseswww aasld orgspecialthankstodr donovan bibliography bailey b amre d andgaudreault p fulminanthepaticfailuresecondarytoacetaminophenpoisoning asystemicreviewandmeta analysisofprognosticcriteriadeterminingtheneedforlivertransplantation critcaremed2003 31 299 305craig d g n lee a hayes p c etal reviewarticle thecurrentmanagementofacuteliverfailure alimentarypharmacologyandtherapeutics2010 31 345 348ganem d andprince a hepaitisbvirusinfection naturalhistoryandclinicalconsequences nengljmed 2004 350 1118 29ghabril