Friday, May 22, 2015

Management of inpatients with cirrhosis

Via ACP Hospitalist Weekly, here are some tips from a talk given at Internal Medicine Meeting 2015.

SBP, an ever present threat

Up to a third of patients with ascites will have this on admission regardless of the reason for admission, which is why paracentesis is recommended on all patients.

The use of albumin

As quoted from the ACP Hospitalist Weekly article:

If you find SBP, treatment is 25% albumin, 1.5 g/kg on day 1 and 1 g/kg on day 3, and cefotaxime or a fluoroquinolone (unless the patient was already on a fluoroquinolone for prophylaxis). Patients who have been diagnosed with SBP will need to continue prophylaxis indefinitely, Dr. Young said.

If you think a patient needs therapeutic paracentesis because of large fluid volume, remember that nature abhors a vacuum, Dr. Young told attendees. "If you pull a lot of fluid out of the belly, they're going to get arterial dilation, they're going to get hypotensive, they get significant untoward events. It's called postparacentesis circulatory dysfunction," he said.

To combat this, give 25 g of 25% albumin for every 5 L of fluid removed, provided kidney function is normal, he noted. In patients with renal insufficiency, use 12.5 g per each 1 to 1.5 L of fluid instead. If the patient has pulmonary hypertension, give the full dose of albumin before the fluid is removed to avoid any potential complications, Dr. Young said.

Upper GI bleeds complicating cirrhosis

According to the speaker infection of some sort is present in 50% of patients, so antibiotics are recommended. The speaker recommended a hemoglobin goal of 8. I am not sure what this means in terms of a transfusion threshold but 7 is now considered evidence based, pretty much across the board.

You can give acetaminophen judiciously.

If you have to give something for pain or fever it's at least better than NSAIDs.

If a stable patient decompensates while in the hospital---

From the article:

"If somebody decompensates, remember GI bleed," Dr. Young said. SBP is also a common cause of decompensation, he noted. "If you tapped them when they came in and they didn't have [SBP], and they remain in the hospital for a little while, and all of a sudden they're just not doing well for reasons you can't entirely explain, don't forget to go back and perform a paracentesis there," he said. If the patient didn't get imaging, it's important to look for hepatocellular carcinoma, a not uncommon cause of decompensation, he noted.

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