Critical care of the end-stage liver disease patient awaiting liver transplantation

Abstract

Patients with end‐stage liver disease awaiting liver transplantation frequently require intensive care admission and management due to either complications of liver failure or to intercurrent illness, particularly infection. Mortality in such patients is high and the development of an illness necessitating intensive care unit management can influence transplant candidacy. Specialized support frequently requires hemodynamic support, mechanical ventilation, and renal support. In this review, areas of management of particular importance to patients with end‐stage liver disease in the intensive care unit are discussed. These areas are hepatic encephalopathy, infectious diseases, cardiovascular support, mechanical ventilation, renal support and combined transplantation, and decisions regarding delisting. Current knowledge specific to these patients, when available, is discussed, current practice is described, and areas of uncertainty in the evidence are discussed. Liver Transpl 17:496–510, 2011. © 2011 AASLD.

Specific Nursing Care Rendered In Hepatic Encephalopathy: Contemporary Review and New Clinical Insights

“…The intake of lactulose, a non-absorbable disaccharide which reduces the level of serum ammonia concentration, as well as its absorption, is the cornerstone therapy in the overall strategy of HE treatment [4,16,17]. A patient should not be administered any oral therapy two hours before and after the intake of lactulose to achieve full therapeutic effect of administered drug.…”

“…The development of hepatic encephalopathy is a poor prognostic sign and is related to less than 32% of survival rate during first year. The most significant cause of this disease in the developed countries is alcohol abuse [4,5]. In Asia and Africa the most common cause of liver cirrhosis is hepatitis B virus (with or without delta antigens) [6].…”

Outcomes following liver transplantation in intensive care unit patients

“…Vasopressor requirement and intubation have been considered to be contraindications to transplantation and regarded as criteria for delisting [6] . We sought to investigate whether any of the above factors which have been traditionally linked to worse outcomes would be prognosticators of poor outcomes in our experience.…”

“…Liver disease is progressive in nature and the care for such patients is complex and challenging. As a result, transplant candidates may require intensive care unit admission while awaiting transplantation [5,6] . It is not uncommon for some patients to have multiorgan system failure (MOSF) requiring ventilatory support, hemodynamic support, and renal replacement therapy (RRT) in the course of their disease.…”

“…Criteria that are used to delist a sick patient are transplant program dependent. Many regard ventilatory support and vasopressor therapy in a cirrhotic patient as contraindications to proceeding with transplantation [6] . The aim of our study was to determine the feasibility of LT in patients from the ICU by estimating graft and patient survival in this patient group and also compare these outcomes with non-ICU patients.…”