• Alcohol
    • Systemic effects
      • CNS
        • Wernicke's, peripheral neuropathy
      • CVS
        • Cardiomyopathy, CCF, HT, AF/SVT/VT, autonomic dysfunction
      • GI
        • ALD, Pancreatitis, PVD, oesophageal/bowel Ca
      • Metabolic
        • Inc lipids, obesity,hypoglycaemia, hypomagnesaemia, hypophosphataemia
      • Haem
        • High MCV, low plt, leukopenia
      • MS
        • Myopathy, osteoporosis, fractures
    • AWS
      • Sweating, tremor, HT, inc reflexes, anxiety, agitation, hallucinations, seizures.
    • Post-op complications 2-5x more likely
      • ARDS more common
      • Low surfactant
      • Seizures
      • Immonodeficiency
      • Poor wound healing
      • Low glutathione
    • 3 subsets
      • Steatosis
        • Resolves within a few months, occurs in 90-100% of all heavy drinkers
      • Alcoholic hepatitis
        • Flare up or SIRS type response. 40% go on to develop cirrhosis
          • Rx steroids (pred 40mg/day for 7/7
      • Cirrhosis
        • Hepatocellular damage causes collagen deposition with increased resistance to hepatic flow and portal hypertension
      • Additional risk factors
        • Obesity, hepC
    • Assd with 95% mortality if has cirrhosis and renal failure
    • Management on ITU
      • General resuscitative measures
      • Na containing fluids ok in acute situations
      • Treat oliguria aggressively
      • Don't rapidly correct hyponatraemia
      • Withdrawal regime & ulcer prophylaxis
      • Prophylactic antibiotics in bleeding patients
      • Drainage of ascites if oxygenation or perfusion troublesome. 100ml of 20% albumin for every 3L removed. Spironolactone, furosemide, sodium/fluid restriction
      • SBP suggested by 250 neuts/mm³, Rx with antibiotics and 1.5g/kg IV albumin and 1g/kg at 48 hrs
      • HRS
        • Type 1
          • Rapid over 2 weeks
          • Rx with terlipressin and albumin
        • Type 2
          • Slow progressive deterioration
      • ? TIPS
    • Child-Pugh
      • Bilirubin
        • <34 (1), 34-50 (2), >50 (3)
      • Albumin
        • >35 (1), 28-35 (2), <28 (3)
      • INR
        • <1.7 (1), 1.7-2.2 (2), > 2.2 (3)
      • Ascites
        • None (1), controlled (2), refractory (3)
      • Encephalopathy
        • None (1), I-II or controlled (2), III-IV or in controlled (3)
      • 5-6 = Class A, 7-9 = B, 10-15 = C
    • GA Mx
      • RSI
        • Higher dose of induction agent in chronic intake due to P450 2E1 induction.
        • Distribution altered by low albumin
          Drug metabolism altered due to hepatic impairment
    • Pre-op
      • CAGE >2
        Intake
      • Examination
        • Stigmata of CLD
        • CVS
        • CNS
          • Confusion
          • Neuropathy
          • Autonomic dysfunction
      • Ix
        • MCV high
        • Low folate
        • Low plt
        • Coagulopathy (high PT)
        • Pancytopenia
        • ECG
        • CXR
      • Treatment
        • Pabrinex
        • Vitamin K
        • FFP/plts
    • CEACCP
      Link:ceaccp.oxfordjournals.org/content/9/1/10.full.pdf