Liverfailure Sub acuteliverfailureLowestriskofcerebraloedema encephalopathyEasilyconfusedwithCLDAscitesLowestchanceofspontaneoussurvival Hyper acuteliverfailureAcuteliverfailureGreatestriskofcerebraloedema CVSfailureGreatestchanceofspontaneoussurvival CauseAgentresponsibleViralHepatitisA B DE othersDrugrelatedIdiosyncraticanddoserelatedToxinsCarbontetrachloride PhosphorousAmanitaphalloidesVasculareventsIschemichepatitis Budd Chiari VOD heatshockliverOtherPregnancyrelated Wilsondisease lymphoma PrincipleCausesofAcuteLiverFailure NopreviousliverdiseaseVariousdefinitionsJaundiceorsymptomstoencephalopthy DecompensatedchronicliverdiseaseDecompensationwithsepsisBacterialperitonitis Rxas peritonitis Bacteraemia chest urineVaricealbleed frequentlyseptic endoscopicskills TIPSEncephalopathyHepatorenalfailureAlcoholichepatitis steroids pentoxifylline feed deltabilirubinDifferentialwithALF HistoryPatternofLFT sImaging ultrasound CTscanBiopsy varyrarelyindicatedLivertrauma Multisystemdisease CoagulopathyINRimportantprognosticindicatorinestablishedALFPlateletdysfunctionDIC rareMetabolicInsulinresistance ClarkeetalHepatologyHyperlactataemia BernaletalLancet2002 usefultotrackLivernetproduceroflactateMurphyetalCritCareMed2001P04 Mg Na glucose K pHHighincidenceofpancreatitisNutritionFrequentpoorrecentoralintake vomitingNoevidenceforproteinrestrictionineitheracuteorCLDGastricprophylaxisIncreasedmetabolicrequirementsWalshetalCCM2000 28 3 649 54 Renalfailure Common45 ofallcasesMultifactorial frequentlyprerenal ATNratherthanHRSRoleofintra abdominalpressureSpecificassociationswithviraldisease alcohol auto immuneCRRTorslowhaemodialysisisidealAnticoagulationepoprostenol heparin regionalanticoagulation citrate Infection ALF ImpairedinnateandcellularimmunityBacterialinfection335of887patients 550episodes Severesepsis58 mortalitySepticshock98 mortalityFungalinfection99of887 11 64 mortalityRolandoetalHepatology200032 734 31 4 872ComponentsofSIRSassociatedwithencephalopathyRolandoetalHepatology2000 32 734 9 VaqueroetalGastroenterology2003 125 755 64 ShawcrossDetalJHepatolinpressCultures Antibiotics broadinitially 5 7courseAntifungalsNobenefittoroutineprophylaxisorSelectivegutdecontaminationRolandoetalSeminLiverDis1996 16 389 402 RolandoetalLiverTransSurg1996 2 8 13 VasopressorsinALF Whatmeanarterialpressure Clinicalexamination invasiveDeterminedbyJVsaturationandICP autoregulatingornot Whichdrug DeterminefluidresponsivenessinitiallyWhateveryoucangetyourhandsonInsepsisandMOFepinephrinemaybedetrimentalincreasessplannchnicV02 glucoseturnoverMeierHellmanetal1997CritcareMedPhenylephrine decreasedflowwithdecreaseinsplV02ReineltCritCareMed1999 27 325NorepinephrineasfirstchoiceVasopressinmaybepotentiallydetrimental cerebralcomplicationsandpotentialsplanchnicischaemia ResultsstratifiedaccordingtobloodpressureondayofSST 0 500 1000 1500 NSP 0 01P 0 05 Baseline Increment Peak P 0 001 HarryetalHepatology2002 mortalityassociatedwithlowerbaselineandincrement p 0 05 correlateswithAPACHEIIIandSAPSNocorrelatewithotherparametersotherthancholesterol 57 ofpatientshaveabnormalsynacthenresponsehypotensionassociatedwithlowerbaselineandincrement p 0 05 Marik2005CCM53 1254LDLcholesteroldidseparategroups8 2 7 6vs28 4 14Mortality39 vs56 75 ofthoseonpressorshadabnormalresponse Encephalopathy HEofAcuteLiverFailureHepatocellularfailureRapidonsetCerebraloedemaMyoinositollevelsnotreducedCytotoxicandvasogenic PortalSystemicEncephalopathyPortalsystemicshuntspontaneouscollateralSurgicalTIPPSNotatriskofcerebraloedemaPrecipitatingfactorsSepsisSBPRxfluids AlbuminAvoidrenalfailureCNSactivedrugsElectrolyteabnormalitiesDiuretics overuseGastrointestinalbleeding HepaticencephalopathyinCLD Notacauseofdeath ProvidingtheairwayismanagedTreatprecipitatingcause sepsisscreen fluids AssociationofSIRSwithencephalopathyFeed stdprotein highcalorie fibrecontentideallyvegetablebasedLactuloseandenemas cleaningoracidificationAls NielsonBMJ2004 328 1064Non absorbableantibioticsDecreasingammoniatherapies i ornithineand ii benzoateBenzodiazepineantagonists noefficacyPomiers LayrarguesHepatology198910 969Sedation realriskinwardenvironmentYes theyareamenace upallnight climbingintothewrongbed shouting Progressiveneuropsychiatricsyndrome progressiveneuralinhibitionOccursinbothacuteandchronicliverdiseaseClinicalstatemaychangeveryrapidly IncidenceofcerebraloedemaReviewed229patientsGradeIII IVcoma1999 2002IncidenceHyperacute 24 Acute 23 Subacute 9 NH4NeurosteroidsInflammatoryresponse LarsenNeurochemInternational2004 44 ShawcrossLancet3652005 Increasedammoniaincerebraldeaths splanchnicammoniaproductionLarsenetalHepatology1998NH4cutoff124 pH cerebraloedema NH4predictoutcomeBhatiaVGut2005PartialpressureNH4correlateswithlevelofencephalopathyKramerHepatology2000 21CBFvariable lossofautoregulationtopressureTerlipressininALFShawcrossetal Hepatology2004 39 2 464 70 JalanetalGastroenterology2004 27 1338Cooledto32 33oC PREPOSTn 7ICP45 25 49 16 13 17 CBF103 25 134 44 24 75 CPP45 37 56 70 60 78 CI9 8 7 13 5 1 4 3 6 1 ArterialNH4343 109 490 to259 100 453 Uptake2 6 0 6 6 3 to 0 3 3 1 1 4 JalanetalLancet354 9185 11641999 N 14 ReductioninICPintreatmentgroup p 0 005 MurphyetalHepatology2004 39 2 464 70 Reducedriskofintracranialhypertension p 0 05 AgitationandairwaymanagementGradeIII IntubateventilateandsedatewithopiateandpropofolControlventilation avoidalkalosisPosition 10to20degreesheadupInsertreversejugularline JVsat55to80 Tightcontrolofglucose K pH Na 145 150mmol L MurphyetalHepatology2004 39 2 464 70Ammonia earlyCRRTMAP 65 frequentlynotautoregulating needtomeasureICPTreat ICP pupillaryabnormalitiesMannitol150ml20 osmolarity150 pressors fever hyperacuteandacute pupilllaryabnormalitiesTemperature avoidfever hypothermiashouldnotbeundertakenroutinely Currentlyavailable PhaseIIIstudywithBALDemetriouetalAnnSurg2004 239660 670 MARSTherapyMitzneretalLiverTranspl2000 6 277 286 HeemannetalHepatology2002 36 949 58 24patientswithCLDand acuteliverinjury MARSgroup reducedbileacids bilirubin encephalopathyControls biochemistrystatic worseningencephalopathyMARS11 12 SMT6 12 P 0 05 6mnthsurvival6 12MARSvs4 11 CoagulopathyandMARStreatmentinCLDDoriaetalClinicaltransplantation2004 18 365SinglePassAlbuminDialysis SPAD Clearanceofbilirubin bileacids NH4 improvedSauerHepatology2004 39 1048 MARSNathanetalLiverTransplant2004 10 1109LaiWetalIntCareMed2005 18patientswithalcoholrelatedAoCLDrandomizedtoMARSorSMTover7daysSignificantimprovementinencephalopathyNochangeinrenalfunctionorcreatinineNochangeinammoniaorcytokinelevels TNF IL 6 IL 10 IL 8 MDA MELDfellinbothgroups10patientswithALFgradeIII IVcomaTreated8hourson2consecutivedaysIncreaseSVRIonfirstRx1114 196to1432 245 changesnotsignificantbyendofsecondRxNochangeinICP14 5 7 25 to14 3 25 MARS SMTvs SMTAcuteonChronicLiverDiseasen 70SignificantimprovementsinencephalopathygradeNodifferencesinsurvivalHassaneinetalAASLD2004 OutcomeofCLDinITUWehleretalHepatology2001 34 255 261 143patients observationalstudy ApacheIII 90 pressors Clinicaljaundice 92 1monthMortalityvs11 inthosewith 3criteria420patientsGildeaChest2004 126 1598 30patientswithHRF8 3030daysurvival median21 Ventilatedsurvival0 15Non ventilatedsurvival8 15NodifferenceINR alb pressorsJGastroenterologyandHepatologyWitzkeetal200419 1369 AccuracyofICUscoringsystems ChildPugh0 72MELD0 72APACHEII0 78SOFA0 80 363patientswithCLDadmittedtoLITU PSE CVS RENALfailure 98 MortalitySOFAscorecutoff 13 Guidelinesforreferral ArterialpH3 0day2or 4 0thereafterINR 1 8oliguriaand