2024 CPD

Question 1

Acute Liver Failure

Answer 1

Evidence of coagulation abnormality (INR >1.5) with any degree of mental alteration (encephalopathy) in a patient without pre-existing cirrhosis and with an illness of less than or equal to 26 weeks duration.

Patients with acute liver failure in the ED may progress to multiorgan failure unless treatment is initiated early. The cytokine release in liver failure and necrosis kicks off a systemic inflammatory response, causing vasodilation and hypoperfusion.

Question 2

Acute on Chronic Liver Failure

Answer 2

Sudden hepatic decompensation observed in patients with pre-existing chronic liver disease and associated with one or more extrahepatic organ failures

Question 3

Decompensated Cirrhosis

Answer 3

A decompensating event is defined as any of the following 4 events:

Ascites
Gastrointestinal bleeding
Hepatic encephalopathy
Bacterial infection

Question 4

Portal Hypertension
Acute Decompensation Liver Failure

Answer 4

Portal Hypertension is a conditon of increased hydrostatic pressure in the portal vein.
This causes reflex dilation of splanchic arteriolae, and via circulatory dysfunction to vasodilation of periepheral arteries.
This can lead to esophageal, gastric and rectal varicies.

Question 5

What causes gastrointestinal bleeding in liver failure?

Answer 5

Spontaneous rupture of varix, ascites owing to hydrostatic pressure itself or spontaneous bacterial peritonitis owing to a leaky intestinal barrier.

Question 6

Systemic Inflammation
Liver Failure

Answer 6

C-reactive protein and leukocytes as biomarkers of Systemic inflammation are higher in patients with pre-ACLF.
In ACLF the inflammatory response is more pronounced.

Question 7

Metabolic Dysfunction
Liver Failure

Answer 7

SI and AD cause hypermetabolic states in which micronutrients such as glucose, amino acids and fatty acids are preferentially held available for immune cells with high metabolic demand.
Deprivation of nutrients can lead to mitochondrial dysfunction in the kidney, heart and liver.

Question 8

Proven Bacterial Infections
Liver Failure

Answer 8

Bacterial infections with an identifiable source meaning postive cultures.
Inappropriate antimicrobial therapy is associated with development of ACLF and increased mortality.

Patients with liver cirrhosis have an increased susceptibility to bacterial infections due to a compromised immune system, portal hypertension due increased portal venous flow and hepatic resistance, thrombosis due to complex alterations in the coagulation factors and hypoalbuminemia, and bleeding due to portal hypertension as well as complex alterations in the coagulation factors .

Question 9

Multidrug-Resistant Infections
Liver Failure

Answer 9

Multidrug-resistant gram negative bacteria are more common in ACLF.

Question 10

Severe Alcoholic Hepatitis

Answer 10

Dysfunction to the immune system, dysfunctional neutrophils.
Contributes to mitochrondial dysfunction.

Question 11

Acute Liver Failure
Supportive Care

Answer 11

Intravenous fluids and maintenance of acid base levels and normal electrolytes.
Vasopressors to maintain a MAP greater than 75 mm Hg to ensure renal and cerebral perfusion.
Monitor hematocrit for any bleeding, as patients have coagulopathy and poor platelet function. Patients should be started on proton pump inhibitors for prohylaxis of gastrointestinal bleed.
Maintain 1.0 to 1.5 grams of protein per kilgram per day.

Question 12

Renal Failure
Liver Failure

Answer 12

Continuous renal replacement therapy is preferred to hemodialysis.

Question 13

Meabolic Disorder
Liver Failure

Answer 13

Hypoglycemia occurs due to impaired gycogen production and gluconeogenesis.
D10W or D20W infusion should be used.
Alkalosis in ALF is due to hyperventilation and acidemia below pH 7.3.

Question 14

Cerebral Edema
Liver Failure

Answer 14

Most common cause of death in ALF is cerebral edema which leads to intracranial hypertension, ischemic brain injury and herniation.

Caused by accumulation of ammonia.

Consider hypertonic saline and target Sodium of 145 - 150 mmol/L

Question 15

Liver Enzymes

Answer 15

Liver Enzymes include AST, ALT, ALP, and GGT and the measured levels indicate degree of cell death/damage to the liver.

Question 16

Liver Function Tests

Answer 16

Liver function tests include INR, PTT, Albumin, and Bilirubin and indicates the synthetic capability of the liver.

Question 17

What Liver Function Tests are elevated due to hepatocellular damage?

Answer 17

ALT & AST

Question 18

What Enzymes are elevated due to cholestatic damage?

Answer 18

ALP and GGT
Elevated when there is a problem with the flow of bile from the liver to the small intestines.

Question 19

Common disease states that cause acute liver failure.

Answer 19

Acetaminophen toxicity
Drug induced liver injury
Viral hepatic diseases
Autoimmune diseases
Mushroom toxicity
Wilson’s disease

Question 20

Non-Dihydropyridine Calcium Channel Blockers

Answer 20

Non-Dihydropyridine CCBs (Verapamil and Diltiazem) tend to cause myocardial suppression more than vasodilation. Typical presentation includes early development of hypotension and bradycardia.

Question 21

Dihydropyrindine Calcium Channel Blockers

Answer 21

Dihydropyridine CCBs (Nifedipine, Amlodipine, etc.) initially cause vasodilation. However, at high doses lose selectivity for the vasculature and suppress the myocardium

Question 22

How is glucose affected in calcium channel blocker toxicity versus beta-blocker toxicity?

Answer 22

CCB poisoning usually causes hyperglycemia, whereas BBl poisoning may cause hypoglycemia.

Question 23

Lipophilic agents (propranolol)
Toxicity Issue

Answer 23

More likely to enter the brain and cause delirium or seizure.

Question 24

Cardiac Sodium Channel Blockers
Toxicity Issues

Answer 24

(acebutolol, betaxolol, carvedilol, oxprenolol, pindolol, propranolol)
May cause QRS widening and monomorphic VT. EKGs may also reveal a Brugada pattern.
Hypotension can be more severe than one would expect, based solely on the degree of bradycardia.

Question 25

Cardiac potassium chanel blockers
Toxicity Issues

Answer 25

(acebutolol, sotalol) may prolong the QTc and cause torsade de pointes.

Question 26

Activated Charcoal

Answer 26

Patient presents within 1-2 hours of ingestion (which rarely happens).

Question 27

Whole Bowel Irrigation

Answer 27

Whole bowel irrigation should be considered for large ingestion of sustained-release medications or amlodipine (which may function as a long-acting medication).
In order to be effective, bowel irrigation should be performed early (prior to the onset of shock and ileus).

An isotonic solution of polyethylene glycol (i.e., “GoLytely”) may be infused via an orogastric tube, beginning at a rate of 1.5-2 liters/hour. If emesis occurs, reduce the rate by 50%.

Continue until effluent is clear