Intensive liver care

The Liver Intensive Care Unit in Apollo Hospitals, Greams road, Chennai is a dedicated 12 bedded advanced critical care unit dedicated to postoperative management of Liver Transplant recipients and management of patients with liver failure .

TEAM

The unit comprises of a dedicated team of Intensivists with vast experience in managing Liver Transplant and Liver Failure patients. Our Lead Consultant has an experience of managing over 1000 Living-donor and Deceased-donor Liver Transplant patients and is ably assisted by a highly qualified, well-trained and experienced team of dedicated doctors. The intensive care team works in tandem with senior Hepatologists and Liver Transplant Surgeons. The team is experienced in managing complex problems and multiorgan dysfunction associated with liver disease. 24 hours onsite Consultant level care is ensured to maintain consistency in the quality of care for the patient. The team takes care of the preoperative optimization of Liver Transplant patients, selection and ensuring fitness, perioperative care and post-transplant recovery resulting in continuous high quality and safe care. The Liver ICU is well supported by allied department Consultants who are pioneers in their respective fields. A dedicated Infectious Disease Consultant and Infection Control team help to keep infections under control in this group of immunosuppressed patients.

The nursing staff play a vital role in the management of Liver Transplant and Liver ICU patients. The team consists of highly qualified nurses who are specially trained in handling high-risk patients. A 1:1 nursing ratio is maintained for critically ill patients in the liver ICU which helps improve care, safety and reduce infections.

The Liver ICU has its own dedicated team of Respiratory Therapists who play a crucial role in the weaning and rehabilitation of critically ill patients. Nutritional management is handled by a team of Dietitians who have extensive experience in rehabilitating malnourished cirrhotic and bowel failure patients using enteral and parenteral supplements.

LIVER ICU MODEL

Apollo Hospitals follows up to date evidence based protocols to treat all complex medical conditions. Protocols are drawn out in multidisciplinary meetings that are conducted periodically to help improve the consistency and safety in the care. All clinical pathways are updated and compliance is monitored closely.

Management of respiratory failure due to ARDS or Pulmonary Edema is done with lung protective strategies. All modalities of Dialysis are available and instituted in cases of Renal Dysfunction, Sepsis or Multiorgan Failure. Postoperative goal directed therapy and enhanced recovery after anesthesia protocol helps improve outcome and shorten the Average Length of Stay in the Liver Intensive Care Unit.

The Multidisciplinary team including Intensivists, Hepatologists, Transplant Surgeons, Senior Critical Care Nurses, Respiratory Therapists and Dietitians visit patients on a daily basis. Apollo Hospitals is a regional referral centre for Hepatobiliary and pancreatic disorders and liver trauma.

High dependency Unit

High Definition Unit is a step-down Intensive Care Unit to care for patients whose body functions need to stabilize. The care provided to patients at the HDU is at an intermediate clinical level with expert medical care, nursing care and monitoring facilities. All the facilities of a full state ICU are kept ready to deal with any contingent complication for a patient in the HDU. The HDU is specifically staffed with a nurse assigned to each unit for monitoring the patient.

Infrastructure

At Apollo Hospitals, services are delivered at world-class standards and the facility is equipped with state-of-the-art technology. The ICU is HEPA filtered to manage post-transplant and immunosuppressed patients. All post-transplant patients are kept in strict contact isolation with barrier nursing. The ICU provides advanced Haemodynamics management using equipment including transpulmonary cardiac output monitoring, advanced ventilators for invasive and non-invasive artificial respiration, crash cart with defibrillators, round-the-clock bedside ultrasonography, transthoracic echo, and trans-esophageal echo (TEE). In coordination with the Nephrology team, all modalities of dialysis – Conventional Hemodialysis, Slow low Efficiency Dialysis(SLED), Continuous Renal Replacement Therapy (CRRT) are available through the day and can be quickly instituted when required. Equipments for plasma exchange therapy required to bridge liver failure in ALF and ACLF are also available round the clock.

SERVICES

Liver Transplantation

Patients who need Liver Transplantation are monitored by the Intensive care team preoperatively and thoroughly assessed. The cardiopulmonary reserve of the patient to undergo the transplant is assessed in conjunction with the Cardiologist and Pulmonologist. In the event of significant deviations, steps are taken to optimize the preoperative cardiopulmonary, renal and nutritional status of the recipient to ensure that the transplant surgery is safe. Each patient’s detail is presented in a multidisciplinary meeting including Liver Intensivists, Transplant Surgeons and Hepatologists.

Immediate postoperative morbidity is a major determinant for the long-term outcome after liver transplantation. The impact of the physiologically demanding surgery on the already deranged organ functions seen in end stage liver disease, needs to be well handled in the critical care unit . The critical care team performs several functions such as monitoring patients post-transplant, stabilising organ functions, weaning off support, managing intraoperative challenges, evaluating the transplanted liver and establishing immunosuppression. Components of critical care include hemodynamic monitoring, respiratory and neurological management, fluid optimization, electrolyte, acid base and glucose correction, coagulation management, systemic immunosuppression, and monitoring graft function. Any medications needed in the postoperative period have to be screened for possible interactions with immunosuppressive medications.

There are patients who may need transplantation of both the liver and kidney together. Combined liver and kidney transplantation can be challenging as it involves carrying out two major operations on a sick patient simultaneously and needs management by a multidisciplinary team of Liver and Kidney Transplant Surgeons, Liver and Kidney Physicians, Dialysis Teams and Intensive Care Specialists. Apollo Hospitals has successfully carried out the country’s largest number of Combined Liver and Kidney Transplantations.

TREATMENT OF SPECIFIC CONDITIONS

Acute Liver Failure management

Patients with Acute Liver Failure may initially appear relatively well but can rapidly progress to develop multi-organ failure. Managing patients with multiorgan failure is quite challenging. Our team has extensive experience in handling such patients with individual organ function optimization, liver supportive therapy like plasma exchange and bridging patients to transplant when indicated. Intensive multiorgan support with ventilation, blood pressure support, extracorporeal filtration of blood,intracranial pressure reduction strategies are routinely undertaken.

Some of these patients with multi-organ failure may recover with intensive medical treatment alone.But when they do not respond to medical treatment, they would immediately need to undergo Liver Transplantation. Urgent living donor or deceased donor liver transplantation is lifesaving in this situation. Apollo Hospitals is one of the very few liver units in the country having the ability to manage such sick patients and undertake liver transplantation on an emergency basis.

Acute Pancreatitis management

We are a regional referral centre for patients with acute pancreatitis. We work closely with the hepatobiliary surgeons and specialist interventional radiologists to manage patients as effectively as possible.

TREATMENT MODALITIES

  • Circulatory Support
    • Vasopressor/inotrope therapy
    • Advanced haemodynamic monitoring – Transpulmonary thermodilution and pulmonary artery catheterization
    • Management of aortic balloon pump
    • Transthoracic and transoesophageal echocardiography
    • Veno-arterial and Veno-venous ECMO (extra-corporeal membrane oxygenation)
  • Ventilatory Support
    • Conventional and high-frequency oscillatory ventilation
    • Ultrasonic nebulisation
    • Bronchoalveolar lavage
  • Renal Replacement
    • Continuous veno-venous haemofiltration/haemodiafiltration
    • Sustained low efficiency dialysis
  • Management of severe sepsis/septic shock

    • Extracorporeal cytokine removal
  • Management of Acute Liver Failure
    • Reverse jugular oxygen saturation monitoring
    • Management of Intracranial pressure
    • Therapeutic Plasmapheresis/plasma exchange
    • Emergency liver transplantation
  • Management of Acute Pancreatitis and complications of chronic pancreatitis
  • Management of decompensated chronic liver disease and complications of portal hypertension
    • Hepatorenal syndrome/acute kidney injury
    • Ascites/spontaneous bacterial peritonitis
    • Variceal haemorrhage
    • Management of Acute on Chronic liver failure
  • Management of complex hepatology patients
    • Viral Hepatitis
    • Acute alcoholic hepatitis
  • Management of hepatobiliary surgical patients
    • Hepatobiliary and pancreatic tumour
    • Postop management of liver resection and Whipples procedures
  • Therapeutic endoscopy for massive gastrointestinal bleed
    • Endoscopic banding, glue injection
    • Esophageal stenting for refractory bleed
  • Interventional Radiology
    • Angiography/embolization
    • Transjugular intrahepatic portosystemic shunt (TIPS procedure)
    • Trans Arterial embolization for ruptured tumors
    • Percutaneous Trans Hepatic Biliary Interventions
    • Transjugular and Percutaneous Liver Biopsy
    • Portal Vein Embolization (PVE)
  • Liver transplantation
    • Deceased donor liver transplantation
    • Living-related liver transplantation
  • Assessment for major surgery
    • Risk assessment and diagnostic right heart catheterization
  • Short stay and Peri-operative Care
    • Post-operative goal directed therapy/optimization
  • Management of trauma/polytrauma

ACADEMIC AND RESEARCH ACTIVITIES

Teaching and training

All Clinical Consultant staff participate in teaching which include didactic sessions, bedside teaching, journal club, morbidity, mortality and radiology for junior faculty and nursing staff. We are in the process of starting a fellowship program in Liver Transplant and HPB Anesthesia & Critical Care and Nursing fellowship for Liver transplant anesthesia and critical care nursing

Research and development

Plans are afoot for expanding research into immune dysfunction, acute on chronic liver failure, renal and adrenal failure, encephalopathy, prognostic modelling, cardiorespiratory pathophysiology and trials in the efficacy of extracorporeal liver assist devices, acute liver failure and cerebral oedema, sepsis, alcohol related liver disease and viral hepatitis.

Ongoing Research

  • Develop new definitions and criteria for ACLF and cirrhosis-associated AKI
  • Use/ modify CLIF-SOFA scoring systems for better prognostication of liver failure patients
  • Preoperative nutrition and performance status and its implications on post transplant outcome
  • Protocol for managing liver failure patients

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