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  1. Home
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  3. Core Topics in Critical Care Medicine
  • Cited by 2
Publisher:
Cambridge University Press
Online publication date:
July 2010
Print publication year:
2010
Online ISBN:
9780511712289
DOI:
https://doi.org/10.1017/CBO9780511712289
Subjects:
Anesthesia, Intensive Care, Pain Management, Medicine
Information

Book description

The critical care unit manages patients with a vast range of disease and injuries affecting every organ system. The unit can initially be a daunting environment, with complex monitoring equipment producing large volumes of clinical data. Core Topics in Critical Care Medicine is a practical, comprehensive, introductory-level text for any clinician in their first few months in the critical care unit. It guides clinicians in both the initial assessment and the clinical management of all CCU patients, demystifying the critical care unit and providing key knowledge in a concise and accessible manner. The full spectrum of disorders likely to be encountered in critical care are discussed, with additional chapters on transfer and admission, imaging in the CCU, structure and organisation of the unit, and ethical and legal issues. Written by Critical Care experts, Core Topics in Critical Care Medicine provides comprehensive, concise and easily accessible information for all trainees.

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Contents

Page 2 of 3

Contents
  • Chapter 20 - Acid–base abnormalities
    pp 148-158
  • View abstract

    Summary

    This chapter discusses the importance of pain relief, source of pain, types and severity of pain and modalities of pain relief. Paracetamol is very useful for soft tissue pain and as an opioid sparing drug in more severe pain states. Non-steroidal anti-inflammatory drugs (NSAIDs) are powerful analgesics, particularly useful for bony pain. Tramadol is an atypical analgesic with antagonist actions at morphine receptors and inhibitory effects on the reuptake of serotonin and norepinephrine from the synaptic cleft. Potentiation of serotinergic neurons may be important in activating the descending pain control neuronal pathways. Opioids are the most potent analgesics widely available and form the basis of most critical care pain management treatments. The different opioids discussed in the chapter are: morphine, diamorphine, fentanyl, alfentanil, remifentanil, codeine, ketamine and nitrous oxide. Regional anaesthesia is commonly provided in conditions where the pain intensity is expected to resolve over time.
  • Chapter 21 - Post-operative critical care
    pp 159-169
  • View abstract

    Summary

    There are many clinical scoring systems to provide an assessment of levels of sedation, and commonly used ones include Ramsay and Bloomsbury scales. The other assessment tools are electroencephalograms, bispectral index, and auditory evoked potentials. It takes four half-lives of a drug given by intravenous infusion to achieve steady state. It is therefore necessary to start with a loading dose to minimize delays to achieve adequate sedation. The side effects of sedatives, ideal properties of sedatives, and commonly used sedatives are discussed in this chapter. The chapter reviews intravenous anaesthetic agents, volatile anaesthetic agents, benzodiazepines, opioids, alpha-2 receptor agonists, neuroleptic agents, neuromuscular blockade, and use of protocols and sedation breaks. The recent Awakening and Breathing Control (ABC) trial suggested that a 'wake up and breathe' protocol that pairs daily spontaneous awakening trials with daily spontaneous breathing trials results in better outcomes for mechanically ventilated patients in intensive care.
  • Chapter 22 - Post-resuscitation care
    pp 170-176
  • View abstract

    Summary

    Ordinarily, when discussing treatment options with a patient, doctors manage to fulfill an ethical obligation by ensuring that the patient's treatment choices are accommodated as far as possible. The four key ethical principles are: beneficence, non-maleficence, respect for autonomy, and justice. One of the cornerstones of good medical practice is that before providing treatment or involving a patient in teaching, or research, doctors must be satisfied that they have a valid authority. Usually this requires the patient to consent to the proposed treatment. In critical care the hardest decisions are those concerning when to withhold or withdraw treatment. Despite this the majority of patients who die in critical care departments do so after a decision to withhold or withdraw life-prolonging care. When considering end-of-life issues, good communication with patients and their relatives is essential for establishing priorities and ensuring that the wishes of the patient are paramount.
  • Chapter 23 - Bleeding and clotting disorders
    pp 177-184
  • View abstract

    Summary

    There are four types of organ donation: living donation, xeno-transplantation, non-heart-beating donation (NHBD) and heart-beating donation (HBD). All patients who have confirmed brainstem death can be heart-beating donors. NHBD should be considered in any patient who is above 60 years of age, and has an irreversible condition so that after withdrawing treatment death is inevitable. The Advisory Committee on the Microbiological Safety of Blood and Tissues for Transplantation (MSBT) provides national guidance on donor evaluation and testing. The public is very supportive of organ donation in principle, with 15 million already on the NHS Organ Donor Register. However, the actual donation rate remains poor, partly due to 40% of relatives refusing to give consent. In 2006, the UK government set up the Organ Donation Taskforce (ODTF) to identify barriers to organ donation and draw up actions needed to increase organ donation.
  • Chapter 24 - Acute coronary syndromes
    pp 185-193
  • View abstract

    Summary

    The inflammatory response is a central component of sepsis as it drives the physiological alterations that are recognized as systemic inflammatory response syndrome (SIRS). In contrast to the hypothesis of exuberant inflammatory response in sepsis is the finding that septic patients may have a relative anti-inflammatory environment. Cellular death may be a key factor in sepsis and its related mortality. Cells that are destined to die can do so by two mechanisms: apoptosis and necrosis. In sepsis, cytokine-induced coagulopathy triggers increased activity of tissue factor (TF) and plasminogen activator inhibitor-1 (PAI-1) and decreased levels of the natural anticoagulant protein C on mononuclear and endothelial cells. Critical illness related corticosteroid insufficiency (CIRCI) occurs as a result of either a decrease in adrenal steroid production. In patients with severe sepsis, a strategy of glycaemic control using intravenous insulin should include a nutritional protocol with preferential use of the enteral route.
  • Chapter 26 - Acute heart failure
    pp 202-211
  • View abstract

    Summary

    Multiple organ failure (MOF) can affect any organ and systems not thought of as organs such as endocrine, immune, haematological and therefore it has also been called multiple systems organ failure (MSOF). Patients with multiple organ dysfunction syndrome (MODS) make up 10-15% of the intensive care unit population and typically have two to three organ system dysfunctions at time of diagnosis; hypoxia, shock and oliguria are the most common combination. The different components of MODS are: respiratory system, renal system, gastrointestinal system, hepatic system, neurological system, haematology, immunology, and endocrinology and metabolism. No single treatment for MODS can be recommended because it is a maladaptive response to acute severe inflammation and therefore a complication to be prevented rather than a syndrome to treat. Patients with impaired host defence mechanisms are at greatly increased risks of developing sepsis and MODS. Sepsis requires urgent antibiotics and source control with or without surgery.
  • Chapter 27 - Mechanical ventilation
    pp 212-225
  • View abstract

    Summary

    An immunosuppressed patient is unable to mount the normal, co-ordinated immune response to trauma and infection. Respiratory failure or sepsis are the commonest reasons for immunosuppressed patients to require ICU admission. Respiratory failure can result from multiple simultaneous pulmonary processes, both infectious and noninfectious. As a consequence of both the primary illness and its treatment, patients with malignancies are prone to episodes of neutropenia. Despite rigorous screening, transmission of infection from the donor organ can occur. With the advent of highly active antiretroviral therapy (HAART), the prognosis of patients with HIV and AIDS has improved enormously. Splenic macrophages have an important filtering and phagocytic role in removing bacteria and parasitized red cells from the circulation. Life-threatening infection is a major long-term risk post splenectomy. Most serious infections are due to encapsulated bacteria. Lifelong antibiotics should be offered to all patients; however, the first 2 years post splenectomy appear especially important.
  • Chapter 28 - Failure of ventilation
    pp 226-231
  • View abstract

    Summary

    Antibiotics should only be administered after microbiological specimens are taken, except in emergencies. Most antibiotics are removed from the body via the kidneys. Renal failure may cause the accumulation of a drug, or its metabolites. This is a particular problem with glycopeptides and aminoglycosides where toxic levels are associated with severe and permanent side effects such as ototoxicity and renal impairment. Organisms resistant to multiple antibiotics such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) have emerged in healthcare environments and have proved difficult to control in many countries. Prophylaxis is recommended where a bacteraemia is expected, and the resultant infection may result in significant morbidity or mortality. The commonly used antibiotics on intensive care unit are: beta-lactams, carbapenems, aminoglycosides, glycopeptides, quinolones, macrolides, rifampicin, oxazolidinone and nitroimidazoles. The three major classes of anti-fungal drug are: azoles, polyenes, and echinocandins.
  • Chapter 29 - Failure of oxygenation
    pp 232-240
  • View abstract

    Summary

    Fluid and electrolyte balance is an important everyday practice on the intensive care unit. The different types of fluids are crystalloids that include Hartmann's solution, normal (isotonic) saline, dextrose, and colloids that include albumin, starch and gelatins. The disorders of sodium concentration are nearly always caused by excess free water (hyponatraemia) or free water loss (hypernatraemia). The potassium balance is affected by hypokalaemia and hyperkalaemia. The abnormalities in magnesium are caused by hypomagnesaemia and hypermagnesaemia. The abnormalities in phosphorous are caused by hypophosphataemia and hyperphosphataemia. The abnormalities in calcium are caused by hypocalcaemia and hypercalcaemia. Hypercalcaemia is not a common problem in intensive care. In 90% of cases, the underlying cause is hyper-parathyroidism or malignancy. Treatment is indicated when the hypercalcaemia is associated with adverse effects, or when the serum calcium is greater than 14 mg/dl (ionized calcium above 3.5 mmol/l).
  • Chapter 30 - Respiratory weaning
    pp 241-245
  • View abstract

    Summary

    Disorders of acid-base equilibrium are common in critically ill and injured patients. The presence of these disorders often signals severe underlying pathophysiology and, particularly in the case of metabolic acidosis, is a significant marker of adverse outcome. The traditional theory makes us believe that the hydrogen ion concentration (pH) in blood is mainly influenced by balance between the carbon dioxide and the bicarbonate ions in the blood. An acid load sufficient to reduce an unbuffered solution to a pH less than 2 only reduces the blood pH of an animal by 0.3 pH units. Disturbances of the acid-base equilibrium have their own morbidity and mortality. A blood pH less than normal (normal range 7.35-7.45) is called acidaemia; the underlying process causing acidaemia is called acidosis. Similarly, alkalaemia and alkalosis refer to a raised pH and the underlying process, respectively.
  • Chapter 31 - Non-invasive ventilation
    pp 246-250
  • View abstract

    Summary

    The main aim of post-operative care is prevention, early identification and treatment of post-operative complications. This chapter discusses monitoring of vital parameters, post-operative analgesia, systemic pain relief, fluid balance, cardiovascular system, nutrition, orientation, and care of drains and wounds during the early post-operative period. In the late post-operative method, control of infection is done with appropriate antibiotics after culture and sensitivity if required. Prophylaxis of deep vein thrombosis (DVT) is important following major surgeries and orthopaedic surgery. Good physiotherapy support in the post-operative period for lungs and mobilization helps prevent many complications associated with major surgery. Prevention of pressure ulcers is a critical part of postoperative management. The patient has to be turned frequently in the bed to prevent the pressure ulcers. Central to a good perioperative outcome is a multi-disciplinary approach to promote effective and early therapy.
  • Chapter 32 - Unconventional strategies for respiratory support
    pp 251-256
  • View abstract

    Summary

    Current theories on the concept of a post-resuscitation syndrome describe the development of a systemic inflammatory response/sepsis following resuscitation from cardiac arrest. Critical care treatments during the post-resuscitation phase should focus on correcting hypoxia and hypercarbia, optimizing organ perfusion, identifying and treating the underlying cause of the cardiac arrest and optimizing neurological outcomes. Several randomized controlled trials and a meta-analysis have shown that therapeutic hypothermia is associated with improved survival and neurological outcome in initially comatose survivors of cardiac arrest. Observational studies in cardiac arrest survivors have shown that hyperglycaemia after return of spontaneous circulation is associated with an adverse outcome. Myocardial dysfunction is common after cardiac arrest and usually starts to improve within 72 hours after return of spontaneous circulation. Acidosis and control of seizures are explained in this chapter. The ability to predict the likely neurological outcome of a patient following admission to critical care is important.
  • Chapter 33 - Acute gastrointestinal bleeding and perforation
    pp 257-265
  • View abstract

    Summary

    This chapter discusses the cell-based model of coagulation, regulation of coagulation, and bleeding disorders. The disorders include congenital disorders and acquired disorders such as thrombocytopenia, disseminated intravascular coagulation (DIC) and microangiopathic haemolytic anaemia. Thrombocytopenia may occur because of impaired production, sequestration, increased consumption, and enhanced degradation. Activated protein C has been shown to reduce mortality in sepsis especially in patients with DIC and multi-organ failure. During the resuscitation of patients who have suffered a major haemorrhage, factors that can contribute to associated coagulopathy are: hypothermia, metabolic acidosis, and consumption of clotting products. Heparin-induced thrombocytopenia (HIT) usually occurs 5-10 days following exposure to heparin. It is a pro-thrombotic disorder and can lead to significant venous and arterial thrombosis. HIT usually resolves following the discontinuation of heparin over a few days. Management includes the prompt removal of all heparin containing medication and the substitution of a direct thrombin inhibitor to control clotting.
  • Chapter 35 - Poisoning
    pp 275-283
  • View abstract

    Summary

    Patients with acute coronary syndrome (ACS) are classified into ST segment elevation myocardial infarction (MI), and non-ST segment elevation MI. An ECG should be obtained on admission and the ST segments are monitored. Patients with ST segment depression have a poorer prognosis when compared with patients with T wave abnormalities. An elevation in biomarkers indicates myocardial necrosis. The preferred biomarker is cardiac troponin (I or T) which has a sensitivity of 100% 6 hours after the onset of MI. Creatine kinase CK-MB is the best alternative when troponin is either unsuitable or not available. This chapter discusses management of ST-elevation ACS using percutaneous coronary intervention (PCI) or fibrinolysis, heparin, antiplatelet therapy, rescue PCI, and surgical revascularization. Non-ST-elevation ACS management strategy is based on low-risk patients, and intermediate and high risk patients. Oxygen and pain relief are given to all the patients along with an antiemetic agent in adjunctive therapy.
  • Chapter 36 - Liver failure
    pp 284-291
  • View abstract

    Summary

    Cardiac arrhythmias can be broadly classified based on the heart rate as bradyarrhythmia (<60 bpm) and tachyarrhythmia (>100 bpm). Physiological bradycardia can often be found in athletes whilst pathological bradycardia signifies sinus node or conduction pathway abnormalities, which may or may not be associated with drugs, autonomic or endocrine dysfunction. Acute management of arrhythmias depends on the haemodynamic status of the patient and the type of arrhythmia. Patients who exhibit adverse features will require urgent treatment to resolve the arrhythmia. Narrow complex and broad complex tachyarrhythmias without adverse signs are managed differently in the acute setting. Most sinus tachycardias are related to underlying causes and will resolve once the cause is rectified. Broad complex tachycardias are due to a number of underlying rhythms. In the long term, implantable cardiovertordefibrillator (ICD) insertion is beneficial for patients who have structurally abnormal hearts with ventricular arrhythmias.
  • Chapter 37 - Acute renal failure
    pp 292-298
  • View abstract

    Summary

    Acute heart failure (AHF) may arise from systolic or diastolic dysfunction, rhythm disorder or preload and afterload mismatch from various aetiologies. The strongest sign is presence of a S3 or gallop rhythm on auscultation. Other clinical signs depend on the aetiology of AHF and its correlation with the history helps guide further investigation and treatment. The investigation is performed by electrocardiogram, and imaging techniques such as chest X-ray, computed tomography (CT), and echocardiography. For optimal management of AHF, full blood count, clotting, urea and electrolytes, blood glucose, cardiac enzymes, inflammatory markers and arterial blood gas analysis are recommended. The other investigations for AHF include coronary angiography, endomyocardial biopsy, and CT angiogram. The invasive monitoring of AHF is performed by arterial line, central venous lines, pulmonary artery flotation catheter and echocardiography. The management of AHF includes ventilatory support, the use of inotropes and renal replacement therapy.
  • Chapter 38 - Renal replacement therapy
    pp 299-305
  • View abstract

    Summary

    Mechanical ventilation is in general indicated where established or impending respiratory failure exists. Respiratory failure occurs when pulmonary gas exchange is sufficiently impaired to cause hypoxaemia with or without hypercarbia. The respiratory failure is classified into two broad categories: Type 1 (or hypoxaemic) and Type 2 (or hypercarbic) respiratory failure. This chapter talks about mechanical ventilators, airway pressure, and flow and derived volumes. The different modes of ventilation are: volume control ventilation, pressure control ventilation, mandatory breaths and spontaneous breaths. The chapter reviews alternative ventilation modes, practical aspects of mechanical ventilation, and complications of mechanical ventilation. It explains different ventilatory strategies for specific conditions such as acute lung injury/acute respiratory distress syndrome, chronic obstructive pulmonary disease, acute asthma and brain injury. A care bundle approach for the care of a ventilated patient should include thromboprophylaxis, gastric protection and evaluation of sedation status.
  • Chapter 39 - Status epilepticus
    pp 306-311
  • View abstract

    Summary

    The three parts of the respiratory control system are: sensors, central control and respiratory muscles. The different disorders of ventilation include hypoventilation syndromes and hyperventilation syndromes. The three main types of hypoventilation syndromes are: obesity hypoventilation syndrome, respiratory neuromuscular disorders and primary alveolar hypoventilation. Alveolar hyperventilation exists when PaCO2 decreases below 4.5 kPa. It is not the same as hyperpnoea which is increased minute ventilation with a normal PaCO2. Detailed history and clinical examination along with knowledge of coexistent disorders can provide clues to the cause of hyperventilation. An elevated pH is suggestive of a primary respiratory alkalosis; a low pH will show a metabolic acidosis. Widened A-a gradient suggests presence of a primary pulmonary disorder. Low bicarbonate suggests a chronic nature of the disorder and implies an organic cause. Transcutaneous PCO2 or arterial PCO2 during sleep studies can help to exclude psychogenic hyperventilation.
  • Chapter 40 - Abnormal levels of consciousness
    pp 312-318
  • View abstract

    Summary

    This chapter describes oxygen cascade, and monitoring of gas exchange by pulse oximetry, capnography and blood gas analysis. Hypoventilation is a reduction in the volume of gas delivered to the alveoli causing hypoxia. Ventilation/perfusion mismatch is responsible for the hypoxaemia seen in pulmonary oedema, chronic obstructive pulmonary disease, pulmonary embolism and interstitial lung disease. Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) describe a spectrum of a critical illness syndrome involving severe inflammatory disease of the lung. Positive end expiratory pressure (PEEP) is used to improve oxygenation and prevent lung shear-stress injury associated with the opening and closing of collapsed alveoli. However, PEEP can also cause cardiovascular compromise and increased airway pressures and overdistension. The classification of pulmonary embolism by its clinical effects is: small pulmonary emboli, submassive pulmonary emboli, and massive pulmonary emboli. Surgical and catheter-based thrombectomy are alternative strategies in the management of massive pulmonary emboli.
  • Chapter 41 - Meningitis and encephalitis
    pp 319-324
  • View abstract

    Summary

    Respiratory weaning is classified into simple weaning, difficult weaning and prolonged weaning. When the patient successfully completes the spontaneous breathing trial (SBT), weaning can then be started using one of the three ways: moving from assist control to higher levels of pressure support ventilation, using synchronized intermittent mandatory ventilation with an initial higher rate which can be decreased over time, and continuing full ventilatory support with intermittent trials of low levels of pressure support or continuous positive airway pressure (CPAP). The chapter outlines the role of tracheostomy and non-invasive ventilation in weaning. Proportional assist ventilation (PAV) is a form of synchronized partial ventilatory support in which the ventilator generates support in proportion to the patient's instantaneous effort. Adaptive support ventilation (ASV) is based on a computer-driven closed loop regulation system of ventilator settings which are responsive to changes in both the respiratory system mechanics and spontaneous breathing efforts.
  • Chapter 42 - Traumatic brain injury
    pp 325-333
  • View abstract

    Summary

    The applications of non-invasive ventilation (NIV) include: acute exacerbation of chronic obstructive pulmonary disease (COPD) and cardiogenic pulmonary oedema, for immunocompromised patient, during failure to wean from ventilation. It is essential before NIV is initiated that arterial blood gas measurements be available. The patient should be established upon appropriate oxygen therapy and interpretation must be made in the context of the FiO2. Correct patient selection is essential for the success of NIV: it is a complementary not alternative therapy to IPPV. The successful instigation of NIV is very dependent upon establishing a good rapport with the patient and inspiring confidence in what will feel like a very unusual treatment. The complications of NIV include mild gastric distension, pressure effects of the mask and straps causing facial tissue damage, eye irritation, sinus pain or nasal congestion, and significant haemodynamic effects resulting from NIV that are unusual although hypotension may occur.
  • Chapter 43 - Trauma and burns
    pp 334-341
  • View abstract

    Summary

    A range of interventions has been devised to try to extend the potential range for conventional ventilation, as well as alternative strategies to support patients with respiratory failure beyond the current limits of conventional ventilation. Given that in the majority of patients acute respiratory distress syndrome (ARDS) is reversible, placing the patient in the prone position during conventional ventilation can improve oxygenation failure in this setting. Recruitment manoeuvres (RMs) are used to improve the volume of aerated lung, and consequently hypoxaemia, principally in patients receiving conventional ventilation for ARDS. In adult practice in the UK, high-frequency oscillation (HFOV) is generally used as a rescue for ARDS patients with refractory hypoxaemia on conventional ventilation. Extracorporeal CO2 removal potentially offers a rescue intervention in patients with severe hypercarbic respiratory failure. Transtracheal gas insufflation (TGI) appears a promising complementary technique to mechanical ventilation.
  • Chapter 44 - Eclampsia and pre-eclampsia
    pp 342-348
  • View abstract

    Summary

    The three common forms of presentation for acute gastrointestinal (GI) bleeds are: haematemesis, melaena, and haematochezia. This chapter discusses the complications associated with GI bleeding and management of GI bleeding. It lists the commonest causes of upper GI bleeding, and explains management of non-variceal upper GI bleeding and upper GI bleeding indications for surgery. Gastro-oesophageal varices are dilated submucosal veins which occur in approximately 40-60% of patients with cirrhosis. Control of active variceal bleeding has been shown to be achievable with sclerotherapy (80%) or band ligation (94%). The chapter discusses the incidence of upper GI perforation and lower GI perforation. Approximately 15% of patients with diverticulitis develop bowel perforation. The mortality rate is high (20-40%) as patients may suffer from sepsis and multiorgan failure. The chapter discusses initial management, specific management and post-operative complications of bowel perforation. Endoscopic treatment achieves haemostasis in the majority of patients with non-variceal bleeding.
  • Chapter 45 - Obstetric emergencies in the ICU
    pp 349-359
  • View abstract

    Summary

    After gallstones, alcohol is the second most common cause of acute pancreatitis. The mechanism of alcohol-induced acute pancreatitis is incompletely understood, although some evidence points to increased sensitivity of acinar cell cholecystokinin receptors leading to increased release of trypsin. Patients typically present with pepigastric pain, often radiating to the back, accompanied by nausea and vomiting. On account of the wide spectrum of disease severity in acute pancreatitis there is particular interest in prognostic indicators that may help to determine the requirement for therapeutic interventions. A number of scoring systems such as Glasgow score, have been developed to attempt risk stratification in acute pancreatitis. The mainstay of treatment in severe acute pancreatitis is supportive care. The mortality associated with the first peak in the biphasic mortality curve is attributable to systemic inflammatory response and multiple organ failure. Full intensive care support may be necessary including ventilatory, cardiovascular and renal support.
  • Chapter 46 - Paediatric emergencies
    pp 360-368
  • View abstract

    Summary

    Deliberate self-poisoning is usually an intentional oral ingestion of a variety of drugs by previously well adults and makes up 95% of cases. This chapter explains airway and breathing, and circulation in the initial assessment and resuscitation phase. In the clinical examination the patient's symptoms and signs elicited on physical examination provide clues to the most likely drugs involved and guide early therapy especially when the cause is unidentified. The chapter lists out various investigations that include electrocardiogram, arterial blood gases, radiology and drug screening. The importance of maintaining physiological stability whilst minimizing the toxic effects of drug ingestion is paramount. The toxicity can be diminished by preventing drug absorption, inhibition of toxic metabolite formation, and augmentation of drug elimination. The general care of the unconscious patient includes regular monitoring of vital signs and organ support. The chapter lists out management of specific drugs that include salicylates (aspirin).
  • Chapter 47 - Core areas required for UK/European Diploma examinations
    pp 369-373
  • View abstract

    Summary

    Paracetamol poisoning is the most common cause of acute liver failure (ALF) in Western Europe, Australia and USA. The N-acetyl derivative of the amino acid cysteine (NAC) serves as a precursor to the production of glutathione and is the treatment of choice in early paracetamol toxicity. Patients with hyperacute or acute liver failure often require significant volumes of fluid resuscitation. Patients with liver failure are prone to hypoglycaemia. Liver failure leads to a loss of synthetic function of hepatocytes and reduction of coagulation factors, and international normalized ratio (INR) is a very important prognostic factor. The complications of liver failure include hepatic encephalopathy, intracranial hypertension, renal failure and adrenal dysfunction. In a selected group of patients liver transplantation is the treatment of choice. Overall survival, without transplantation, is about 40% following the onset of ALF. Acute on chronic liver failure represents the decompensation of otherwise stable chronic liver disease.

Page 2 of 3

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