Decompensated Cirrhosis Care Bundle form (Figure 1)

What this platform has drawn from it — 12 claims

• The BSG/BASL admission care bundle lists the presentations of acute decompensation of cirrhosis as jaundice, ascites, hepatic encephalopathy and suspected variceal haemorrhage. Page 2, note (1) Presentation of Acute Decompensation of Cirrhosis
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• The care bundle specifies that all patients presenting with symptoms or signs of decompensated cirrhosis should have bloods taken including full blood count, liver function tests, urea and electrolytes, clotting, calcium, phosphate, magnesium, CRP, lactate and glucose, and a septic screen comprising chest radiograph, urine dipstick and blood cultures. Page 1, ALL patients section, First 6 hours
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• The care bundle states that in a patient with clinical ascites a diagnostic ascitic tap is essential, sending fluid for cell count, microscopy culture and sensitivity, protein and albumin. Page 1, ALL patients section, First 6 hours
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• The care bundle specifies that the diagnostic ascitic tap is performed with a green needle irrespective of clotting parameters, with fluid sent in universal containers for albumin and for microscopy culture and sensitivity with a white cell count differential, and into blood culture bottles with a minimum of 5 ml in each to maximise the yield for diagnosing spontaneous bacterial peritonitis. Page 2, note (2) Diagnostic Ascitic Tap
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• The care bundle defines spontaneous bacterial peritonitis by an ascitic neutrophil count above 250 per cubic millimetre, and specifies human albumin solution at 1.5 g/kg of 20% solution together with antibiotics according to hospital guidelines. Page 1, Spontaneous Bacterial Peritonitis section; page 2 note (2)
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• The care bundle applies the KDIGO criteria for acute kidney injury, defined as a rise in serum creatinine of at least 26 micromol/L within 48 hours, a rise of at least 50% over the preceding 7 days, urine output below 0.5 ml/kg/hour for more than 6 hours based on dry weight, or clinical dehydration. Page 2, note (3) Acute Kidney Injury as per KDIGO
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• For acute kidney injury the care bundle specifies suspending all diuretics and nephrotoxic drugs, fluid resuscitation with crystalloid in 250 ml boluses, strict urine output monitoring, and senior review with consideration of escalation to intensive or high dependency care at 6 hours if the patient is deteriorating despite this. Page 1, Acute Kidney Injury section, First 6 hours
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• For suspected variceal haemorrhage the care bundle specifies terlipressin 2 mg intravenously as a stat dose followed by 2 mg four times daily where there is no clear contraindication, prophylactic antibiotics according to hospital guidelines, and octreotide 50 micrograms as a bolus followed by an infusion of 25 to 50 micrograms per hour as an alternative, with beta blockers suspended if terlipressin or octreotide is started. Page 1, GI bleeding section; page 2 note (4) Variceal Haemorrhage
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• The care bundle form states a transfusion target of haemoglobin 7-8 in gastrointestinal bleeding with suspected varices, aiming above 8 in massive bleeding. Page 1, GI bleeding AND varices suspected section
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• The care bundle states that routine administration of platelets, fresh frozen plasma, prothrombin complex concentrate and other products to correct haemostatic tests is not recommended in stable patients outside those taking anticoagulants, and that fresh frozen plasma should be avoided in portal hypertension. Page 2, note (4) Variceal Haemorrhage, stable and unstable patients
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• For hepatic encephalopathy the care bundle specifies lactulose 20 to 30 ml four times daily or a phosphate enema, and a CT head to exclude a subdural haematoma where there is clinical doubt. Page 1, Symptoms/signs of Hepatic Encephalopathy section
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• The care bundle specifies for all patients an abdominal ultrasound including Doppler of the hepatic and portal veins, venous thromboembolism prophylaxis unless the platelet count is below 50 or there is active bleeding, referral to dietetics, and specialist review by the gastroenterology or liver team at the earliest opportunity. Page 1, ALL patients section, First 6 hours
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