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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

General 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

Etiology 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

Complication Specific Management

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

SpO2

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