醫學筆記匯整 ED Notes

General management : 

• Discontinued harmful medication : Herbal, NSAIDs, Alcohol 
• Discontinued HTN medication if MAP < 82mmHg 
• Screen HCC Q6 month
• Screen complications : Varice

Medications : 

Patients with cirrhosis who have a history of HTN gradually
become normotensive and eventually hypotensive as cirrhosis progresses
Discontinued HTN medication if MAP < 82 mmHg

If stable hypotension :  
Midodrine may improve splanchnic and systemic hemodynamic variables,
renal function, and sodium excretion. 

Nonselective beta-blockers reduce portal pressures 
常用來預防 EV bleeding 
beta-blockers are associated
with higher rates of survival only within a clinical window
在 moderate-to-large esophageal varices develop ± variceal bleeding 有幫助
但 refractory ascites, hypotension, the hepatorenal syndrome,
SBP, sepsis, or severe alcoholic hepatitis
(Decompensated cirrhosis) 時已經沒有好處
甚至有 unfavorable hemodynamic effects ( Cardiac reserve ) in advanced cirrhosis




BZDs for sedative should be avoided in patients with hepatic encephalopathy
Acute alcohol withdrawal develop : short-acting BZDs 
Insomnia : hydroxyzine, trazodone 

Statins 在 cirrhosis 病人的使用很安全
比起少數的 Statin induced abnormal liver function 
Statin 降低的 CV risk 更重要 

Arginine vasopressin receptor 藥物
Satavaptan alleviated hyponatremia, but mortality was higher
the use of vaptans in patients with cirrhosis and ascites is not recommended
 

Nutritions : 
Cirrhosis 病人普遍 malnutritions 
建議 Protein : 1-1.5g/kg/d
High-protein diets are well tolerated
and are associated with sustained improvement in mental status, 
whereas restriction of protein intake doesn't have any beneficial effect
in patients with acute hepatic encephalopathy
顛覆的觀念 ? 肝性腦病變不用限蛋白 ?
We avoid protein restriction regardless of whether
they have a history of hepatic encephalopathy.
  
建議 Na < 2g / day 
Na < 120 才限水

Pain control :  
NSAIDs : Risk of Renal failure and GI bleeding

Opioid  should be avoid or used with causions, Tramadol is safe in low dose 
但 low dose Aspirin for CV risk 繼續用

Acetaminophen is effective and safe
一般人 < 4g/ day 
Cirrhosis 建議 < 2g/day 
 

Procedures : 
Invasive procedure risk 很高
可用 MELD 估算 30 day post OP mortality
among patients undergo nontransplantation surgical procedures

Endoscopic procedures are relatively safe. 
 

Paracentesis is relatively safe, even in patients with marked coagulopathy
即使 INR 8.7 + plt 19,000
在 SBP 病人上 delayed paracentesis 會上升死亡率 

- Diuretic-sensitive ascites : 放 5L 就可 reduce intraabdominal pressure
- Diuretic-refractory ascites : Remove as much fluid as possible 

放水 < 5L 不需要 Colloid replacement
Larger-volume paracentesis 建議每放 1L 水就補 6 - 8 g of albumin

若 SBP 建議補少一點 albumin, 
1.5 g per kilogram be given within 6hr after diagnosis
with another 1g per kilogram administered on day 3
Because the probability of survival is not higher when albumin is given 
 

Should a prolonged INR in liver cirrhosis be routinely
corrected with FFP prior to invasive procedure ?

 = No. PT or INR is not a reliable predictor of bleeding tendency in cirrhotic patients. 
 = Platelet < 50,000/uL or fibrinogen < 120 mg/dL is more reliable than PT or INR
     in predicting bleeding risk in cirrhotic patients.
     Targeting INR or PT alone leads to overuse of FFP.

 = Vitamin K replacement usually has a minimal effect.
    The thinking has been that “it does not hurt and may help”
    so there is no harm in adding vitamin K supplementation to the treatment program.
 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4076882/

https://blogs.nejm.org/now/index.php/treatment-patients-cirrhosis/2016/08/25/