REBEL Core Cast 22.0 – Decompensated Liver Disease

Take Home Points

End stage liver disease patients have fragile baseline physiology. Minor insults can have profound effects
Always start with the basics – large bore IV lines
SBP give 3rd generation cephalosporin + albumin in severe disease
Upper GI bleed give appropriate blood products + ceftriaxone

Represents a late stage of progressive hepatic fibrosis characterized by distortion of the hepatic architecture
Essential functions of liver compromised – immunocompromised, vasodilated, hyperdynamic cardiac function at baseline. Not healthy patients!!

Consider them all immunocompromised!
- May lack fever, leukocytosis on presentation – presume they’re all sick
Ask yourself why they’re coming in
- Increasing ascites – why is it getting bigger?
- Hepatic encephalopathy – don’t just treat elevated ammonia, ask why it’s happening
Calculate Shock Index – HR / SBP
- > 0.7 – abnormal
- > 1.0 – worrisome
- Can clue you into patient being hypovolemic before they become hypotensive.
- Note: Many patients are on beta blockers which can mask tachycardia

These patients can be tough vascular access
Central line is not your best bet, get short, fat catheters for great flow rates.
If you can’t get IV access, get an IO in there

Suspect in all patients with ascites
Classic triad of fever, ascites and abdominal pain is rarely present
New renal failure, diarrhea, hypothermia and acidosis are potential presentations
13% will present with no symptoms at all!!
Have a low threshold to tap
- >250 PMN is main diagnostic criteria, also send for cultures
Management
- 3rd generation cephalosporin (ceftriaxone or cefotaxime)
  - Ceftriaxone 25 mg/kg up to 2 gm daily
  - Cefotaxime 25 mg/kg up to 1 gm Q8
- 1.5g/kg of albumin
  - Benefit of albumin is in patient with severe disease with creatinine >1, BUN > 30 or total bili > 4
- Albumin + Antibiotic had 20% reduction in renal failure and a 25% reduction in mortality

Cirrhotic patients develop varices at rate of 5-15% per year
Management
- 2 Large Bore IVs
- Emergency Type O from the beginning
  - Call for 4 Units immediately then switch to type specific
  - Consider massive transfusion protocol
  - O negative for women of child bearing age, O positive for all others
Send off TEG to help guide resuscitation
If no TEG, send Fibrinogen level
- Fibrinogen <100: give cryoprecipitate
Secure airway – consider delayed sequence intubation
- Delayed sequence will allow you to preoxygenate, suction and drop NG tube to decompress GI tract
- Ketamine 0.5 mg/kg IV
Get Blakemore or Minnesota tube ready
Octreotide and PPI do not affect these patients mortality
Give antibiotic!
- Ceftriaxone or other 3rd generation cephalosporin
- NNT of 4 for preventing infection
- NNT of 22 for reducing mortality

Shownotes Written By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

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