What is the management plan for hepatic (liver) failure?

Management of Hepatic Failure

The comprehensive management of liver failure requires systematic diagnostic evaluation, supportive care for multiple organ systems, and early consideration for liver transplantation to reduce mortality and improve outcomes. 1

Diagnostic Evaluation

Initial assessment should focus on identifying the etiology of liver failure, as this guides specific treatments and helps predict outcomes:

• Perform blood analysis including serum acetaminophen levels, hepatitis A (IgM VHA) and hepatitis B (HBsAg and anti-HBc IgM) serology, and toxicology screen in urine for substances like amphetamine and cocaine 1
• Conduct hepatic Doppler ultrasound to exclude chronic liver disease and verify vessel permeability (hepatic veins, portal vein) 1
• Perform echocardiography, especially when ischemic hepatocellular injury is suspected in patients with cardiac failure, arrhythmias, or when AST levels exceed ALT 1
• Measure coagulation parameters (PT/INR, factor V), blood glucose, arterial blood gases, lactate levels, and arterial ammonia 1

Organ System Management

Central Nervous System

• Monitor encephalopathy frequently and maintain serum sodium levels between 140-145 mmol/L 1
• Monitor blood glucose at least every 2 hours 1
• Perform tracheal intubation and sedation for progressive hepatic encephalopathy (Glasgow <8) 1
• Minimize sedation depth and avoid benzodiazepines and psychotropic drugs like metoclopramide 1
• Do not use treatments like lactulose or rifaximin to lower ammonia levels 1

Cardiovascular System

• Assess volume status, cardiac output, and cardiac function 1
• Use crystalloid fluids as first choice for fluid expansion 1
• Administer norepinephrine for refractory hypotension 1
• Consider pulmonary artery catheterization in hemodynamically unstable patients 1

Respiratory System

• Implement standard lung-protective ventilation strategies 1

Renal System

• Provide renal replacement therapy according to specific recommendations 1
• Use continuous rather than intermittent dialysis mode for acute renal failure 1
• Avoid nephrotoxic drugs, including NSAIDs 1

Gastrointestinal System

• Provide stress ulcer prophylaxis 1

Coagulation Management

• Restrict clotting factor administration to cases with active bleeding only 1
• Do not routinely correct coagulation abnormalities 1

Infection Control

• Administer empirical broad-spectrum antibiotics to patients with worsening hepatic encephalopathy or signs of SIRS 1

Specific Treatments

• Administer N-acetylcysteine systematically regardless of suspected etiology 1, 2
• Establish early contact with a transplant unit 1
• Provide etiology-specific treatments (e.g., acyclovir if Herpes simplex virus hepatitis is suspected) 1
• Consider urgent liver transplantation when prognostic indicators suggest high likelihood of death 1

Prognostic Considerations

Poor prognostic indicators that may warrant consideration for transplantation include:

• Etiology: idiosyncratic drug injury, non-hepatitis A viral infections, autoimmune hepatitis, mushroom poisoning, Wilson disease, Budd-Chiari syndrome, or indeterminate cause 1
• Clinical: higher grades of encephalopathy (III-IV) 1
• For acetaminophen-induced ALF: arterial pH <7.3 after adequate volume resuscitation, or PT >100 seconds (INR >6.5) with serum creatinine >3.4 mg/dL in patients with grade III/IV coma 1
• For non-acetaminophen ALF: PT >100 seconds irrespective of coma grade 1

Common Pitfalls and Caveats

• Avoid sedatives and psychotropic drugs that can worsen encephalopathy 1
• Do not use treatments aimed at lowering ammonia levels (lactulose, rifaximin) as they haven't shown benefit in acute liver failure 1
• Avoid nephrotoxic medications including NSAIDs 1
• Don't routinely correct coagulation abnormalities unless active bleeding is present 1
• Remember that despite intensive investigation, the cause of ALF remains unknown in approximately 25% of patients 1
• The transplant-free survival rate varies significantly by etiology: 50% for acetaminophen, hepatitis A, hypoxic hepatitis or pregnancy-related ALF versus <25% for hepatitis B, non-acetaminophen drug reactions, autoimmune hepatitis, Wilson's disease or Budd-Chiari syndrome 1