Management of Acute Viral Hepatitis with Fulminant Hepatic Failure in Children
Early evaluation for liver transplantation is the most critical intervention for children with acute viral hepatitis progressing to fulminant hepatic failure, as this offers the best chance for survival when medical management fails. 1, 2
Initial Assessment and Supportive Care
- Immediate transfer to a pediatric intensive care unit with transplant capabilities is essential for optimal management 3
- Restrict fluid therapy to 50-60% of maintenance volume calculated by the Holliday-Segar formula to prevent fluid overload and worsening of edematous states 4
- Use isotonic maintenance fluids to reduce the risk of hyponatremia; avoid lactate buffer solutions in severe liver dysfunction 4
- Monitor fluid balance, electrolytes (especially sodium), and glucose levels daily to prevent complications 4
- Avoid NSAIDs and aspirin due to increased bleeding risk from coagulopathy 4
- Assess coagulation status - prolonged prothrombin time >90 seconds indicates poor prognosis 5
- Monitor for and treat hypoglycemia aggressively, as it's a common complication in pediatric fulminant hepatic failure 5
Specific Viral Etiologies and Treatments
- For hepatitis B-related fulminant hepatic failure, consider nucleoside analogs (lamivudine, entecavir, or tenofovir depending on age) although their efficacy in the acute setting remains unproven 1
- For children ≥12 years with hepatitis B, tenofovir is preferred due to lower resistance rates; for children <12 years, entecavir may be considered 1
- For suspected herpes virus-related acute liver failure, immediate treatment with acyclovir is recommended and the patient should be placed on the liver transplant list 1
- For hepatitis A, C, and E, management is primarily supportive as no specific antiviral therapy has proven effective in the acute setting 1
Monitoring for Complications
- Assess for hepatic encephalopathy every 2-4 hours using age-appropriate scales; progression to grade 3-4 encephalopathy indicates poor prognosis 2, 5
- Monitor for signs of increased intracranial pressure (headache, vomiting, altered mental status, pupillary changes) 3, 5
- Screen for infections regularly (blood, urine, respiratory cultures) as infections are a major cause of mortality 3
- Monitor renal function closely as renal failure is a common complication in fatal cases 5
- Assess for gastrointestinal bleeding, which is more common in severe cases 5
Criteria for Liver Transplantation
- Failure to improve laboratory tests reflecting liver inflammation or function, especially persistent hyperbilirubinemia 2
- Development of hepatic encephalopathy, particularly grades 3-4 2, 5
- Presence of neurological complications such as brain stem dysfunction, decerebrate posturing, or seizures 5
- Coagulopathy unresponsive to vitamin K with prothrombin time prolonged >90 seconds 5
- Development of renal failure or massive gastrointestinal bleeding 5
Post-Acute Phase Management
- For survivors without transplantation, continue monitoring liver function tests for up to 24 months, as abnormalities may persist despite clinical recovery 5
- For children who received transplants, lifelong immunosuppression and monitoring will be required 3
- Regular ultrasound surveillance every 6-12 months depending on disease severity 4
- Annual monitoring of liver function tests during follow-up 4
Special Considerations
- In immunocompromised children with viral hepatitis, prophylactic treatment with nucleoside analogs should be considered to prevent reactivation 1
- For children with autoimmune hepatitis presenting with fulminant failure, glucocorticoid therapy (prednisone/prednisolone up to 2 mg/kg daily) may be considered, but should not delay transplant evaluation 2
- Educate parents about warning signs requiring immediate medical attention, including worsening jaundice, abdominal distension, mental status changes, unusual bleeding, persistent vomiting, and fever 2