Acute Liver Failure Group 3
October 4, 2022 | Author: Anonymous | Category: N/A
Short Description
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Description
Acute liver failure
Group 3 Leader: Sibay Kyla Assistant Leader: Dejesus, Janszen Castillo Members:
● ● ● ●
Gillian mae Dolosa Nicka marice Majadora Aaron khan Nadduha Donna joy Perez
● Sittienor hannah Sarip ● Gabriel Villegas
Case Scenario
A 64-year-old man, Mr. Koko Melo, with a significant medical history of chronic obstructive pulmonary disease, alcohol alcoh ol abuse, and depression presented pres ented to the intensive intens ive care unit(ICU)of FUMC as a transfer from the emergency department for acute hepatic failure. Melohad reportedly ingested 50 tablets of hydrocodone/acetaminophen (10-325 mg; 16.2 g of acetaminophen)in an attempted suicide 6 hours before arrival at HospitalM. His initial laboratory evaluation was notable for the following: •Ethanol level: 320 mg/dL •Acetaminophen level: 430 μg/mL •Aspartate aminotransferase (AST) level: 2066 U/L •Alanine aminotransferase (ALT) level: 1321 U/L •Potassium level: 5.6 mEq/L •Creatinine phosphokinase (CPK) level: 62,530 IU/L Orders at the ED was to place Mr. Meloon a continuous norepinephrine infusion at 20 μg/h. He was intubated secondary to being obtunded. He underwent treatment for hyperkalemia and was started on intravenous N-acetylcysteine (NAC)200mg/mL as follows: -Loading dose of 150 mg/kg IV; mix in 200 mL of 5% dextrose in water and infuse over 1hour -Dose 2:50 mg/kg IV in 500 mL D5W over 4 hours -Dose 3: 100 mg/kg IV in 1000 mL D5W over 16 hours
Upon admission at the ICU, the patient was afebrile, blood pressure was 94/57mmHg, heart rate of92 bpm, and respiratory rate rat e at22 breaths/min. breaths/min . He weighs 87 kg. His oxygen saturation satu ration was 96% on the ventilator. On examination, Mr. Mel exhibited diffuse jaundice, smelled of alcohol and tobacco, and appeared much older than his stated age. He was in no acute distress. He had bilateral scleral icterus. His cardiopulmonary examination findings were unremarkable for any acute changes. His abdominal examination revealed a fluid wave with the absence of any peritoneal signs. On his 2nd hospital day, laboratory evaluation findings included the following: •Hemoglobin level: 10.5 g/dL •Platelet: 110 x 103/L •Sodium level: 146 mmol/L •Potassium level: 4.6 mmol/L •Blood urea nitrogen level: 26 mg/dL •Creatinine level: 3.02 mg/dL •AST level: 2094 U/L •ALT level: 1685 U/L •Totall bilirubin level: 0.4 mg/dL •Tota •INR: 2.11 •Troponin level: 35.25 ng/mL (increasing to 44.66 ng/mL) •Acetaminophen level: 237 μg/mL •Acetaminophen •CPK level: 57,000 IU/L •ABG: pH = 7.03, paCO2= 41.26 mmHg, HCO3= 6.0 mmol/L, paO2= 112.53mmHg, and a BE =–22.6 mmol/L
Ultrasonography of the abdomen revealed an increased hepatic echogenicity suggesting diffuse hepatocellular disease, cirrhosis, and small amount of perihepatic ascites. Given the Melo’ Melo’ss condition, conservative treatment was recommended. He was started on a low-intensity heparin infusion(UFH 50,000units/5mLinfusion rateof 12 units/kg/hr)for 48 hours. By day 3, Melo’screatinine Melo’screatinine level rose to 4.18 mg/dL, and he was anuric. His AST level level increased to 3895 U/L, and his ALT ALT level increased to 3215 U/L, despite intravenous NAC administration. administration. His lactic acid level increased increased from 2.2 to 8.2 mmol/L, mmol/L, with an an anion gap of 25. He subsequently underwent dialysis. By day 4, vancomycin and piperacillin/tazobactam were initiated for healthcarehealthcareassociated pneumonia. Chest radiography revealed revealed hazy opacities in the lung lun g bases. The transplant surgery team deemed him to be a poor candidate from a surgical perspective for a liver transplant.
Background Background of of the study
Acute liver failure (ALF) is a devastating syndrome that triggers a cascade of events, leading to multiple organ failure and often death. ALF is a syndrome defined by the occurrence of encephalopathy, coagulopathy and jaundice in an individual with a previously normal liver. Patients with high grades of encephalopathy, the chances of survival are less than 20% with medical management alone. Early deaths in ALF are often caused by cerebral oedema or cardiovascular collapse, whereas late deaths tend to result from sepsis and multiple organ failure. O’Grady System Hyperacute (0 - 1 week Acute (From 1 week - 4 weeks) Subacute (From 4th week - 12 weeks)
Causes of Acute Liver Failure
Symptoms
Complications
1. Viral Hepatitis - Hepatitis A, B, C, D, E - CMV, EBV EBV,, VZV 2. Drugs/T Drugs/ Toxins -Acetaminophen -Herbal supplements
Signs and symptoms of acute liver failure may include: Yellowing of your skin and eyeballs (jaundice) Pain in your upper right abdomen Abdominal swelling
Acute liver failure often causes complications, including: Excessive fluid in the brain (cerebral edema). Bleeding and bleeding disorders.
-Antibiotics -Mushroom poisoning 3. Shock/ ischemic liver 4. Alcoholic hepatitis 5. Autoimmune disease 6. Cryptogenic
(ascites) Nausea Vomiting A general sense of feeling unwell (malaise) Disorientation or confusion Sleepiness Breath may have a musty or sweet odor Tremors
Infections. Kidney failure.
ETIOLOGY
Etiology Drug induce (acetaminophen) Risk Factors:
Risk Factors: Modifiable
Non-modifiable -Alcohol abuse -Obesity (patient: 87 kg)
-Age (67 years old) - Gender (male)
Other risk factors: Prescription medications. - Antibiotics - Non steroidal -anti inflammatory drugs - Anticonvulsants - Hepatitis A, B, E
Pathophysiology
Acute Liver Failure
Acetamenophen hepatotoxicty
Damage to the Liver
Lost of Metabolic Function
Loss of parenchyma Liver shrinking to small
ammonia clearance
Hepatic encephalopathy
Change of behavior, reduced alertness, confused, anxiety
hyperammonaemia Cerebral edema Cytotoxic Impaired cellular osmoregulation Astrocyte edema
Intracranial pressure
Hypertension, bradycardia
Massive hepatic necrosis Serum transaminases
Vasogenic Disruption of cerebral autoregulation
Intracranial blood volume & cerebral blood flow.
Elevated systemic concentration of nitric Acid.
Act as potent vasodilator
Clinical manifestation • Jaundice & Bilateral scleral ictus • Ascites
Others •Right abdominal pain •Nausea •Vomiting •Malaise •Disorientation or confusion •Breath may have a musty or sweet odor •Tremors
Pertinent findings ●
Medical history of COPD, alcohol abuse, and depressionDiabetes depression Diabetes testing blood background.. background
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BP was 94/57 mmHgSet mmHgSet of diabetes symptoms with flat design
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HR of 92 bpm RR at 22 bpm
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O2 was 96% on the ventilator
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Diffuse jaundice
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Smelled of alcohol and tobacco
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Bilateral scleral icterus
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Cardiopulmonary examination findings were unremarkable for any acute changes
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Abdominal examination revealed a fluid wave with the absence of any peritoneal signs
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Increase hepatic echogenicity
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Diffuse hepatocellular disease, cirrhosis, and small amount of perihepatic ascites Chest radiography revealed hazy opacities in the lungs
Thank you
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