case liver failure 18-12-09 edited ANISH

Case presentation : 

Case presentation ANISH JOSHI Dept. of Critical Care Medicine Jaslok Hospital & Research Centre

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23 y/F, admitted to a private nursing home C/O: Abdominal pain 3 days Fever 1 day Decreased urine output 1 day Nausea and vomiting 1 day 2

Investigations at nursing home : 

Investigations at nursing home 3

On Examination : 

On Examination Conscious, alert , restless Febrile Tachycardia Tachypnoea Maintaining SpO2 on room air Dehydrated Palpable liver 4

At Jaslok Labs (on admission): : 

At Jaslok Labs (on admission): 5

Differential diagnosis: : 

Differential diagnosis: Viral infection ? Drug induced ? Poisoning ? Budd- Chiari ? Malaria ? 6

IMAGING : 

IMAGING C.T. Abdomen: Mild thickening of terminal ileum and mild pelvic collection. 7 ABG:

Treatment : 

Treatment NBM I.V. Fluids 3rd generation Cephalosporins Anti- malarial N-acetyl cysteine Sodium bicarbonate Blood products Invasive monitoring lines SLED 8

Improvement following SLED : 

Improvement following SLED

Lactic acidosis & drugs : 

Lactic acidosis & drugs

Investigated for the possible causes: : 

Investigated for the possible causes: Viral markers: Negative S. Paracetamol level: 6.1 MCG/ML ( TOXIC: 150 @ 4 HR, 50 @ 12 HR) Urine Toxicology: Negative Auto- Immune markers: Negative Wilson’s disease: Negative S. Cu: 24 MCGM % S. Cu OXIDASE: 12.4 MG Cu content of the liver: 5.6 ug/gm ( n upto 45) Urine Porphobilinogen: Neg 11

Patient worsened : 

Patient worsened Meropenems Vancomycin Flucon Inotropes SLED restarted Blood products

What would you like to do further? : 

What would you like to do further?

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. . . .

MELD Score = 40 : 

MELD Score = 40 3.78 X loge bilirubin (mg/100 mL) + 11.2 X loge INR + 9.57 X loge creatinine (mg/100 mL) + 6.43 (X 0 for alcoholic and cholestatic liver disease, X 1 for all other types of liver disease). If hemodialysis, value for Creatinine is automatically set to 4.0 Range 6 to 40

Liver Transplantation planned! : 

Liver Transplantation planned! All cultures were taken. Coagulation parameters were corrected Electively dialyzed prior to surgery Electively intubated and ventilated Immunosuppression 16

Intra operatively : 

Intra operatively 4 L blood loss Transfusions 14 PRBC 15 FFP 2 SDP 10 Cryoprecipitate 15 pints crystalloids Dialyzed during surgery 17

Post operative : 

Post operative Febrile Conscious and responding Tachycardia Minimal vasopressor support Minimal urine output 18

Treatment : 

Treatment Carbapenem Anti-fungal Anti-viral Immuno-suppressants Diuretics Ventilatory support 19

Labs. : 

Labs. 20

Post operative day 2 : 

Post operative day 2 Febrile Conscious and responding Hemodynamically stable and off supports Extubated Diuretics 21

Post operative day 3 : 

Post operative day 3 Febrile Conscious and responding Hemodynamically stable SLED RTF started but patient did not tolerate 22

Post operative day 4 : 

Post operative day 4 Hemodynamically stable Febrile Vomiting Dyselectrolytemia SLED Pleural tapping 23 TRANSUDATIVE, PH 7.6 WBC 25, N: 35%, L 65% LDH 364

Post operative day 5 : 

Post operative day 5 Febrile Drowsy but responding Tachycardiac,Tachypnoeic Vomiting Minimal vasopressor support ABG INTUBATED 24

Post operative day 6culture reports: : 

Post operative day 6culture reports: Tracheal secretion: A. Baumanii Candida Lusitaniae Femoral dialysis port: A. Baumanii Blood ( P): A. Baumanii Blood ( CVC): A. Baumanii Blood ( dialysis port): A. Baumanii Urine : A. Baumanii Candida Tropicalis Sensitive only to Tigecycline and Colistin. 25

Treatment : 

Treatment Tigecycline Colistin III gen. Cephalosporins Caspofungin Ganciclovir Mycept Methyl prednisolone 26

Post operative day 7 : 

Post operative day 7 NJ tube 27

Post procedure : 

Post procedure Unresponsive Pupils : dilated but responsive Hemodynamically unstable requiring high vasopressor supports Variety of arrhythmias 28

Imaging: : 

Imaging: Multiple hypopdense lesions brain and lung Septic foci? Abscesses? Fungal Infection? Nocardiosis? 29

Organisms causing brain & lung abscesses : 

Organisms causing brain & lung abscesses Immunocompromised Immunocompetent Nocardia spp. Toxoplasma gondii Aspergillus spp. Candida spp. C. neoformans. Streptococcus spp. [anaerobic, aerobic, and viridans (40%)], Enterobacteriaceae [Proteus spp., E. coli sp., Klebsiella spp. (25%)] Anaerobes [e.g., Bacteroides spp., Fusobacterium spp. (30%)] Staphylococci (10%) 30

Treatment : 

Treatment AKT Colistin 2 MU three times a day Daptomycin 350 mg once a day Vancomycin 1 gm once a day Valganciclovir 450 mg twice a day 31

At last : 

At last She was unresponsive High vasopressor supports Ventilatory support with high FiO2 Variety of arrhythmias Severe metabolic acidosis Post operative immunocompromised state 32

Cause of FHF? : 

Cause of FHF? Was transplant indicated? Cause of abscesses?

Slide 34: 

Thanks … 34

Slide 35: 

Brain abscess caused by multidrug-resistant Acinetobacter baumanniiCarlos H. Guinand Vives, Guillermo A. Monsalve Duarte, Sandra Valderrama Beltrán, Johanna Osorio PinzónJournal of Neurosurgery, Aug 2009, Vol. 111, No. 2, Pages 306-310

Slide 36: 

36 Levraut et al. conducted a careful analysis of lactate clearance during CRRT and compared it with endogenous clearance. They found that the median endogenous lactate clearance was 1379 ml/min, while the median filter lactate clearance was 24.2 ml/min. CRRT-based lactate clearance thus accounted for < 3% of total lactate removal.

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