Etiology

A wide range of causes of jaundice may occur in intensive care unit patients, and so accurate assessment of the etiology is crucial ( Table...!). It is also important to exclude fulminant hepatic failure, the diagnosis and management of which is dealt with elsewhere. Exacerbations of underlying chronic liver disease due to surgical, septic, or traumatic stress may be the first presentation of the condition. Even in the absence of overt liver disease, alcoholics may be at greater risk of liver dysfunction during stress states owing to low hepatic glutathione levels. An increased bilirubin load on the liver during sepsis and reabsorption of hematomas are underlying factors in some cases but are unlikely to be the sole cause. Overt hemolysis, either drug-induced or following late transfusion reactions, may also occur. Hepatotoxic reactions to the numerous drugs used in the critically ill are important, and include reactions to anesthetic agents, antibiotics, and total parenteral nutrition. Early studies of patients receiving total parenteral nutrition, where predominantly glucose-based regimens were used, revealed hyperbilirubinemia in up to 26 per cent and abnormalities of alkaline phosphatase in 54 per cent by day 12. Excess use of carbohydrate has a widespread effect on hepatic function and can also alter drug metabolism. If solutions containing at least 40 per cent of calories in the form of lipid are used, the frequency is significantly lower.

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Table 1 Causes of jaundice or abnormal liver blood test during critical illness

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