Friday November 10, 2006
Assessment of cirrhosis !! - Part 1 - Child-Pugh score

Editors' note: We will run this pearl on assessment of cirrhosis in 3 parts.

Part 1 - The Child-Turcotte-Pugh (CPS) score.
Part 2 - "model for end stage liver disease" (MELD) score and
Part 3 to compare both scores.

We are thankful to Dr. Richard Saval, Associate Director, Surgical Intensive Care Unit, Maimonides Medical Center and Assistant Professor of Medicine, Mt. Sinai School of Medicine, NY in helping us out in this series of pearl.


Evaluating prognosis in Cirrhosis via Child-Turcotte-Pugh (CPS) score

In 1964 Dr C.G. Child and Dr J.G. Turcotte from the University of Michigan first proposed the scoring system of prognosis in Cirrhosis. In 1972, it was modified by Dr. Pugh as he replaced criterion of nutritional status with the INR.


1 point to lower value
2 points to middle value and
3 points to highest value

1. Total Bilirubin (mg/dL) less than 2 or 2-3 or more than 3

2. Albumin (g/L) more than 35 or 30-35 or less than 30

3. INR 1.7 or 1.7- 2.2 or more than 2.2

4. Ascites None or Controlled with medication or Refractory

5. Hepatic encephalopathy None or Grade I-II (or controlled with medication) or Grade III-IV(coma)


Interpretation

Class A - if Points are 5-6, life expectancy is 15-20 years and Perioperative mortality is about 10%.

Class B - if Points are 7-9, life expectancy is 10-15 years and Perioperative mortality is about 30%.

Class C - if Points are 10-15, life expectancy is 1-3 months and Perioperative mortality is about 82%

Thursday November 9, 2006
Oral Narcan for opioid induced constipation !

Constipation / ileus is a major issue in ICU since many intubated patients stays on narcotic drips for analgesia. Different meds like dulcolex (bisacodyl), lactulose, enema etc. can be used but if patient on narcotic drip like fentanyl, morphine or dilaudid doesn't get relief from conventional constipation relief agents, oral Narcan (naloxone) can be tried. It provides only local effect - without systemic effect. It is found to have a pretty good margin of safety as when given orally, hepatic metabolism limits systemic bioavailability.

Usual dose noted in palliative literature is 2- 4 mg every 6 hours. Later, if needed either dose can be increased upto 8 mg or frequency can be increased upto every 4 hours. Another recommendation (only for morphine) is to give 10 - 20% of total morphine in previous 24 hours.

If you suspect systemic effect of narcane (consistent with opioid withdrawal) - hold narcane and increase narcotic dose.

It can similarly be used in opioid induce pruritis, common with epidural drips.



References: click to get abstract

1. Opioid antagonists in the treatment of opioid-induced constipation and pruritus. Ann Pharmacother. 2001;35(1):85–91
2. Opioid antagonists: a review of their role in palliative care, focusing on use in opioid-related constipation. J Pain Symptom Manage. 2002;24(1):71–90.
3. Oral naloxone reverses opioid-associated constipation. Pain. 2000;84(1):105–109
4. Low-dose oral naloxone reverses opioid-induced constipation and analgesia. J Pain Symptom Manage . 2002;23(1):48–53.