Acute liver failure resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vendhan Ramanujam M.B.B.S [2]

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Management

Altered mental status & PT prolongation by 4-6 sec or INR ≥1.5 presenting w/ nonspecific abdominal Sx w/o preexisting chronic liver disease, cirrhosis & any illness of <26 wks duration

Acute liver failure

Mandatory hospital admission

w/o altered mental status, significant coagulopathy & abnormal LFT

w/ altered mental status

High dependency ward admission

Worsening mental status

ICU admission

w/ or progression to grade I/II hepatic encephalopathy

Transfer to transplant center

Initial evaluation: Detailed H/o and PE Labs: CBC, PT/INR, serum BCH, ABG, ammonia, acetaminophen & tox screen for other drugs/toxins, viral serology (A-E), autoimmune markers, amylase, lipase, bilirubin:alkaline phosphatase, blood grouping & typing, HIV status

General management

Etiology specific management

Complication specific management

Etiology Specific Management

Continuous monitoring under quite environment w/ preventive treatment strategies

Cerebral edema & increased ICP

Coagulopathy

Drugs

GI bleeding

Hemodynamic instability

Hepatic encephalopathy

Infections

Metabolic disturbances

NAC

Nutritional deficiency

Renal failure

*Monitor ICP, CPP & cerebral oxygenation *Elevate head end to 30° *Monitor fluid status *3% NS *Avoid NGT and suction

*Platelet count & coagulation profile (12th hourly) *Inj. Vit. K *Cryoprecipitate

*Discontinue medications *Avoid nephrotoxic & hepatotoxic drugs

*Ranitidine

*Monitor CVP w/ central venous catheter

*Frequent monitoring of mental status

*CBC (12th hourly) *CXR; sputum, blood & urine cultures (daily) *Cefotaxime, meropenem, fluconazole or vancomycin

*Serum BCH, ABG, lactate (12th hourly) *Serum glucose (2nd hourly)

*NAC (i.v × 2d then P.O.)

*Eternal feeding *Parental feeding

*Urinary I/O

Complication Specific Management

Etiology specific management

*H/o acetaminophen intake *Consider if no H/o but elevated aminotransferase (>3500 IU/L)

*Jaundice, coagulopathy, thrombocytopenia ± hypoglycemia *Hypertension & proteinuria *+ Steatosis during liver imaging or biopsy

*Elevated aminotransferase responding to fluid resuscitation *Associated renal dysfunction & muscle necrosis

*+ Serum autoantibodies *+ Liver biopsy

*Abdominal pain, ascites and hepatomegaly *+ Liver imaging (CT/MRV/venogram/doppler USG)

*H/o hepatotoxic drug intake (<6m) *Unlikely if H/o intake >1 or 2 years

*Massive hepatomegaly *+ Liver imaging & biopsy

*H/o mushroom intake *Suspect if no H/o but severe GI Sx (NVD)

*+ Hepatitis serology *+ Liver biopsy for HSV

*Serum bilirubin >20g/dL, bilirubin:alkaline phosphatase >2.0, low serum ceruloplasmin, elevated serum & urine copper, + KF ring, + liver biopsy

Etiology undetermined

Acetaminophen toxicity

Acute fatty liver of pregnancy/HELLP

Acute ischemic injury

Autoimmune

Budd-Chiari

Drug induced

Malignant infiltration

Mushroom poisoning

Viral

Wilson's disease

Intermediate etiology

*Activated charcoal *NAC

*Deliver immediately

*Manage the cause of ischemia

*Prednisolone *Transplantation

*Transplantation

*Discontinue all possible medications except essential drugs

*Supportive Rx

*Activated charcoal & gastric lavage *Penicillin G or Silibinin *Fluid resuscitation

*Supportive Rx *Lamivudine or adefovir *Acyclovir

*Dialysis or hemofiltration or plasmapheresis or plasma exchange *Transplantation

*Incomplete drug or toxin intake H/O *Transjugular biopsy to R/O mailgnancy, Wilson's disease, autoimmune hepatitis or viral hepatitis

References

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Complication specific management

Ascites

Cerebral edema & increased ICP

Coagulopathy

Hemodynamic instability

Hepatic encephalopathy

Metabolic disturbances

Renal failure

*Therapeutic paracentesis w/ 25% albumin *<3 mEq/Kg of Na daily *Lasix & aldactone

ICP >25 mmHg

+ Bleeding or prior to surgery

*Colloid, dextrose in crystalloid (if hypoglycemic) & 1/2 NS w/ 75 mg/L HCO3 (if acidotic) *Norepinephrine±vasopressin *Hydrocortisone

Grade

*Rx acidosis, alkalosis, hypophosphatemia, hypomagnesemia, hypokalemia or hypoglycemia accordingly

*Continuous venovenous hemodialysis

SjO2

*Platelet transfusion (if ≤50,000/mm2) *FFP /+ rFVIIa (if INR≥1.5)

I

II

III/IV

<80

>80

2nd hourly monitoring in quiet environment in high dependency ward

*ICU management *Stat CT to R/O ICH *Short acting BZD *Lactulose

*ICU management *Intubation & mechanical ventilation *Propofol *Elevate head end to 30° *Quiet environment monitoring for CVP, hemodynamic & renal parameters, serum electrolytes, acid base status & neurological status

20% mannitol

No improvement

Hyperventillation

Worsening

3% NS

Transfer to ICU

Reduce core temperature to 32°-34° (monitor for arrhythmias)

Thiopental 125 mg i.v bolus

Improvement or refractory

Transplantation