NMS. Casos Clínicos

20

Part I ♦ Foundations

Table 1-7: Clinical and Laboratory Evidence of Severe Liver Failure Clinical Indicators Jaundice Ascites Muscle wasting Asterixis Advanced encephalopathy Caput medusa (dilated periumbilical vessels) Splenomegaly History of gastric or esophageal varices

Laboratory Indicators* Decreased serum albumin Increased serum bilirubin Elevated Prothrombin time (PT) Thrombocytopenia *Also indicators of marginal hepatic reserve.

Table 1-8: Child’s Classification of Liver Failure Factor Group A B

C

Bilirubin (mg/dL) Albumin (g/dL)

<2.0 >3.5 None None

2.0–3.0 3.0–3.5

>3 <3

Ascites

Easily controlled Poorly controlled

Encephalopathy

Minimal

Advanced

Nutrition Mortality

Excellent 0%–5%

Good

Poor

10%–15% Q: How does one determine the patient’s operative risk? A: The MELD score is the most common method to assess risk. The MELD score calcula- tion is 21 points, a significant operative risk. SAMPLE >25% A careful examination and laboratory assessment is necessary to assess the risk fully. In this case, the patient has advanced liver failure and is somewhat decompensated, as evidenced by the asci- tes. In addition, the ascites is probably part of the cause of the hernia. Careful examination indicates no evident hepatic encephalopathy and no in- fections but some mild muscle wasting. Laboratory studies reveal serum albumin, 3.2 g/dL; bilirubin, 2.5 mg/dL; prothrombin time (PT), 15 seconds (reference 1.2 seconds; INR, 1.25); serum creatinine, 2.5 mg/dL; and platelet count, 110,000/mm 2 .