RESPIRATORY CRIPPLE WITH CIRRHOSIS

CASE HISTORY:
60 YEAR OLD PATIENT,C/C SMOKER , KNOWN COPD, OSTEOPOROSIS, BPH, WITH NO H/O DM OR HTN IS ADMITTED WITH H/O RESP DISTRESS AND TYPE 2 RESP FAILURE. THE PATIENT WAS GETTING RECURRENT CHEST INFECTION AND DYSPNEA FOR THE LAST 10 YEARS. PREVIOUS CXR SHOWED B/L APICAL OPACITIES SUGGESTIVE OF FIBROSIS. PREVIOUS SPUTUM EXAMINATION FOR MYCOBACT.TB AND MANTOUX TEST WERE NEGATIVE. SUBSEQUENT CT SCAN SHOWED HONEY COMB LUNG WITH APICAL FIBROSIS WITH MULTIPLE CYSTS AND THICKENED PLEURA. CLINICALLY THE PATIENT IS DROWSY, DISORIENTED AND CHEST ON AUSCULTATION REVEALED B/L CREPITATIONS AND RHONCHI, ABDOMINAL EXAM- SPLENOMEGALY WITH ASCITIS . BLOOD INVESTIGATIONS SHOWED, AST-490, ALT-1067, NORMAL COAG PROFILE AND RFT. PATIENT WAS INTUBATED AND VENTILATED IN VIEW OF LOW SPO2 LOW PO2 AND RAISED PCO2 WITH RESP ACIDOSIS. A DIAGNOSIS OF CIRRHOSIS WITH HEPATIC ENCEPHALOPATHY WAS MADE.

CXR  SHOWED   RT APCAL FIBROSIS WITH DEVIATION OF TRACHEA TO THE RIGHT

ISSUES TO BE DISCUSSED ARE
1. HOW AND WHAT AGENTS CAN BE USED FOR SEDATION IN ICU IN VIEW OF HEPATIC DERRANGEMENT?

2. WHAT SHOULD BE THE VENTILATORY MODE?

3.FLUID MANAGEMENT WITH CONSIDERATION TO HEPATORENAL SYNDROME?

4. MANAGEMENT OF NUTRITION IN ICU ESPECIALLY PARENTERAL NUTRITION?

1.SEDATIVE AGENTS OF CHOICE--> THE DRUG OF CHOICE OF SEDATION FOR CIRRHOTICS IS PROPOFOL 0-3 MG/KG/HR , SINCE METABOLISM BY REDISTRIBUTION AND EXTRAHEPATIC MECHANISMS OF METABOLISM ARE HELPFUL. OPIOIDS OF CHOICE ARE MORPHINE 1-3 MG/HR (DUE TO PHASE 2 METABOLISM) MIDAZOLAM INFUSION ALSO SUGGESTED BUT AT A REDUCED DOSE. 0.5-1 MG/HR



2. EVENTHOUGH ASSIST CONTROL OR CONTROLLED MODE VENTILTION ARE USED AS THE STARTING VENTILTORY MODES IN COPD PATIENTS, A CIRRHOTIC PTIENT WITH ALVEOLAR EDMA AND V/Q MSMATCH MAY REQUIRE BIPAP MODE TO AVOID EXCESSIVE AIRWAY PRESSURE AND HYPERINFLATION OR VOLUTRAUMA. A LOW RESP RATE WITH ADEQUATE EXP TIME RECOMMENDED FOR EXAMPLE;  A RR OF 8/MT WITH 1:2 RATIO WILL GIVE 5 SECONDS FOR EXPIRATION AND A RATE OF 6/MT EXP TIME,  6.7 SECS, THUS ALOWING ADEQUATE TIME FOR EXPIRATION TO AVOID AUTO PEEP. IT IS SUGGESTED THAT ADDITION OF EXTRINSIC PEEP UPTO 80% OF INTRINSIC PEEP REDUCES THE PATIENT'S INSPIRATORY EFFORT;    SHOULD WE USE PEEP? AND IF SO HOW MUCH? WHY?
3. FLUID MANAGEMENT: ADEQUATE INTRAVASCULAR FILLING IS NEEDED FOR MAINTAINING PERFUSION TO OTHER ORGANS.--> SALT AND VOLUME RESTRICTION ADVISED TO REDUCE ASCITIS, 0.25% SALINE TO BE USED INSTEAD OF .5% SALINE . APPROXIMATELY 1.5 LITRES OF FLUID/DAY WITH SALT SUPPLEMENTATION OF 88 MEQ/DAY IS RECOMMENDED. COTROLLED SPIRONOLACTONE THERAPY TO PUMP OUT FLUIDS WHILE MAINTAINING POTASSIUM LEVEL IS SUGGESTED.  A CVP CATHETER IS NEEDED FOR FLUID MANAGEMENT AND FOR PARENTERAL NUTRITION(THROUGH A PERIPHERAL ROUTE IF COAGULATION IS DERRANGED).FLUID OVERLOAD IS POORLY TOLERATED AND MAY LEAD ON TO PULM EDEMA, AS DILATED RT VENTRICLE (COR PULMONALE) COMPROMISE THE FUNCTION OF LEFT VENTRICLE. CVP READING MAY BE UN RELIABLE IN PRESENCE OF PULMONARY HYPERTENSION, AND SHOULD BE CAREFULLY FOLLOWED UP
4. MANAGEMENT OF NUTRITION: PARENTERAL NUTRITION RECOMMENDED INTHE CRITICALLY ILL

AIMS:
a. PROVIDE ADEQUATE AMOUNT OF CALORIES WITH MINIMAL VOLUME

b. AVOID AMINO ACID IMBALANCE

c. SHOULD NOT CAUSE ANY ELECTROLYTE IMBALANCE

d. SHOULD NOT AGGRAVATE NEUROLOGICAL STATUS

HEPATIC ENCEPHALOPATHY IS CHARACTERISED BY IMBALANCE OF MONOAMINE NEUROTRANSMITTERS LIKE TRYPTOPHAN TYROSIN, AND PHENYL ALANINE AND REDUCED LEVELS OF BRANCHED CHAIN AMINOACIDS LIKE LEUCINE, ISOLEUCINE AND VALINE( DUE TO PERIPHERAL UPTAKE IN MUSCLE) SO INCREASE BRANCHED CHAIN AMINOACID CONTENT(AS THEY COMPETE WITH LONG CHAIN AMINOACIDS TO CROSS BBB AND THEREBY REDUCE THE CONTENT OF MONOAMINES IN BRAIN. BRANCHED CHAIN AMINO ACIDS ALSO HELPS TO REDUCE THE CATABOLIC RESPONSE AND PROMOTES HEPATIC PROTEIN SYNTHESIS AND LIVER REGENERATION. SUPPLEMENTATION OF POTASSIUM PHOSPHATE ALSO NEEDED TO HELP INCREASE PRODUCTION OF ATP.      EXAMPLE:  HEPATAMINE SOLUTION