What is the immediate management of acute liver failure?

Immediate Management of Acute Liver Failure

The immediate management of acute liver failure requires prompt ICU admission, hemodynamic stabilization, identification of etiology, and initiation of N-acetylcysteine (NAC) for acetaminophen overdose cases while preparing for possible liver transplantation. 1

Initial Assessment and Stabilization

Airway and Neurological Management

• Intubate patients with grade III-IV hepatic encephalopathy for airway protection 2
• Position patient with head elevated at 30 degrees to reduce intracranial pressure
• Monitor mental status frequently with transfer to ICU if consciousness declines
• Control seizures with phenytoin if they occur 2
• Avoid sedation when possible; if needed, use propofol in small doses for patients with advanced encephalopathy

Hemodynamic Support

• Maintain euvolemia with crystalloid fluids; consider albumin for fluid resuscitation 1
• Use vasopressors (dopamine, epinephrine, norepinephrine) to maintain adequate mean arterial pressure 2
• Avoid vasopressin as it may be harmful in ALF 2

Diagnostic Workup

• Measure serum acetaminophen levels regardless of clinical history 1
• Perform complete blood analysis including PT/INR, factor V, complete blood count, liver function tests, arterial blood gases with lactate, and ammonia levels 1
• Conduct viral hepatitis serologies, toxicology screen, hepatic Doppler ultrasound, and autoantibody testing 1
• Consider transjugular liver biopsy if etiology remains unclear after initial evaluation 1

Etiology-Specific Treatment

Acetaminophen-Induced ALF

• Administer NAC immediately without waiting for acetaminophen levels 1
• Loading dose: 150 mg/kg IV, followed by maintenance doses of 300 mg/kg divided into 3 sequential doses over 21 hours 1, 3
• Continue NAC if acetaminophen levels remain detectable or if ALT/AST are still increasing 3

Other Etiologies

• For ischemic injury: Focus on cardiovascular support 1
• For Budd-Chiari syndrome: Consider liver transplantation if significant liver failure is present 1
• For autoimmune hepatitis: Consider steroids 1

Management of Complications

Coagulopathy Management

• Administer vitamin K (at least one dose) 2
• Give fresh frozen plasma (FFP) only for invasive procedures or active bleeding 2
• Administer platelets for platelet counts <10,000/mm³ or before invasive procedures 2

Infection Prevention and Management

• Consider broad-spectrum empirical antibiotics in patients with worsening hepatic encephalopathy or signs of SIRS 1
• Monitor for infections, particularly fungal pathogens 1
• Provide prophylaxis for stress ulceration with H2 blocker or PPI 2

Renal Support

• Avoid nephrotoxic agents 2
• Use continuous modes of hemodialysis (CVVH) rather than intermittent hemodialysis for acute renal failure 2, 1

Metabolic Management

• Monitor glucose, potassium, magnesium, and phosphate closely 2
• Manage hypoglycemia with continuous glucose infusions 1
• Initiate early enteral nutrition (60 grams of protein per day is reasonable) 1

Hepatic Encephalopathy Management

• Consider lactulose administration to reduce ammonia levels, though evidence for outcome improvement is limited 2
• Be aware that lactulose may cause gaseous abdominal distension that could complicate transplantation 2
• Minimize patient stimulation and avoid procedures that cause straining 2

Transplantation Considerations

• Consider expedited liver transplantation for selected patients 1
• Specific indications for urgent transplantation include herpes virus hepatitis, Wilson disease, fulminant autoimmune hepatitis unresponsive to steroids, and Budd-Chiari syndrome 1
• Patients with four or more organ failures at Days 3-7 after diagnosis of ACLF-3 have shown 90% and 100% mortality at 28 and 90 days, respectively 1

Pitfalls and Caveats

• Avoid sedatives when possible as they mask neurological assessment and have delayed clearance in liver failure
• Do not wait for acetaminophen levels to start NAC in suspected cases
• Recognize that vasopressin may be harmful in ALF patients
• Be aware that lactulose, while commonly used, has limited evidence for outcome improvement in ALF
• Remember that patients with grade II or higher encephalopathy should be managed in an ICU setting