The Clinical Problem Solvers Episode 304: Spaced Learning Series – The Journey of 3Hs: Hyperbilirubinemia, Hypoxia and Hemolysis
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Oct 4, 2023 Guests Anna Fretz, Priyanka Athavale, and Kirtan Patolia discuss a case of a patient with hyperbilirubinemia due to alcoholic hepatitis, who later developed hypoxia and hemolysis. They talk about the evaluation of hyperbilirubinemia, the workup for alcoholic hepatitis, and the basics of methemoglobinemia.
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Fractionate Bilirubin First
- Jaundice is best approached by first fractionating bilirubin into indirect versus direct types.
- This directs you toward hemolysis/uptake/conjugation causes for indirect and intrahepatic versus extrahepatic causes for direct bilirubin.
Use Scores To Guide Alcoholic Hepatitis Therapy
- Use the Maddrey discriminate function to decide steroid therapy for alcoholic hepatitis when the score is >32.
- Calculate a Lille score around day 4–7 to assess steroid response and guide continuation.
Systematic Initial Steps For New Hypoxia
- When a patient is hypoxic, first verify pulse oximeter placement and waveform, then try supplemental oxygen to judge A–a gradient.
- If saturation doesn't improve with oxygen, pursue ABG and localize pathology to vessel, alveolus, or shunt.
