REBEL Core Cast 22.0 – Decompensated Liver Disease

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What does the liver do

• Makes most of macrophages and complement proteins
• Produces clotting factors and fibrinogen and Protein C & S and antithrombin
• Produces albumin – creates oncotic gradient

Cirrhosis

• 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!!

Things to consider in presentation of cirrhotic 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

Access

• 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

Spontaneous bacterial peritonitis

• 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

GI Bleed

• 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

Links & Resources:

• REBEL EM: SBP
• REBEL EM: Should you give albumin in SBP
• EMRAP: Paracentesis
• SinaiEM: SBP Pearls
• EMRAP: Placement of Blakemore Tube

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

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