Review Article

Improving Survival in Decompensated Cirrhosis

Table 2

High risk patient (high MELD Score > 30) and recommendations.

ConditionScenarioSpecial recommendations

Airway protection in encephalopathyGeneral(1) Avoidance of BIPAP.
(2) Elective intubation for grade III and grade IV encephalopathy.
(3) Low threshold for intubation.
(4) Continue intubation if transplant likely soon.
(5) Extubate only when convincingly awake for considerable duration.
(6) Postpyloric feeding if intubated.
(7) Avoidance/minimal use of sedatives and analgesics.
Procedures (endoscopy, etc.)Preprocedural preemptive intubation.
TransportationLow threshold for elective intubation for transportation to different centre.

Hepatorenal syndromeProlonged periods of physical inactivity form dialysisNighttime continuous venovenous hemodialysis keeping daytime free for mobilization

Cachexia(1) No protein restriction.
(2) Frequent small meals.
(3) Nighttime meal supplement (postpyloric tube feeds or TPN if diarrhea from lactulose) to avoid triggering of muscle consuming gluconeogenesis.
(4) Aggressive physical therapy.
(5) Periodic visit by medical team member making patient perform simple range of motion exercises for all major joints throughout the day.
(6) Frequent incentive spirometry in daytime.

Infections/sepsisAscites ± SBP, GI bleeding(1) Aggressive screening, prophylaxis and treatment for infections.
(2) Sparing and judicious use of steroids.