What is the management approach for dominant acute hepatic failure?

Management of Fulminant Acute Hepatic Failure

The management of fulminant acute hepatic failure requires immediate comprehensive care with early consideration for liver transplantation, as it remains the definitive life-saving treatment for patients with poor prognostic indicators. 1, 2

Diagnostic Evaluation

• Perform immediate laboratory evaluation including serum acetaminophen levels, hepatitis A (IgM VHA) and hepatitis B (HBsAg and anti-HBc IgM) serologies, urinary toxin screen (amphetamine, cocaine), and coagulation parameters 3, 1
• Conduct hepatic Doppler ultrasound to exclude chronic liver disease, verify vessel permeability, and rule out Budd-Chiari syndrome 3
• Perform echocardiography to assess cardiac function, especially when ischemic injury is suspected 3, 1
• Consider transjugular liver biopsy when autoimmune hepatitis is suspected to establish diagnosis and guide treatment 3, 2
• Monitor arterial blood gases, lactate levels, and arterial ammonia to assess disease severity 1

Etiology-Specific Management

Acetaminophen Overdose

• Administer N-acetylcysteine (NAC) immediately regardless of time since ingestion 2, 4
• Standard dosing: 150 mg/kg loading dose followed by 50 mg/kg over 4 hours and then 100 mg/kg over 16 hours 4
• Consider continued therapy beyond the standard 21-hour protocol if acetaminophen levels remain detectable or liver enzymes continue to rise 4

Viral Hepatitis

• Provide supportive care for hepatitis A and B-related ALF 2
• Administer acyclovir immediately for suspected herpes virus or varicella zoster hepatitis 2

Autoimmune Hepatitis

• Treat with corticosteroids (prednisone, 40-60 mg/day) 3
• Place patients on the transplant list even while administering corticosteroids 3

Acute Fatty Liver of Pregnancy/HELLP Syndrome

• Consult obstetrical services and perform expeditious delivery 3, 2
• Provide supportive care post-delivery 3

Drug-Induced Hepatotoxicity

• Discontinue all but essential medications 2
• Obtain detailed medication history including prescription drugs, non-prescription medications, herbs, and dietary supplements 2

Mushroom Poisoning

• Consider administration of penicillin G and silymarin 2
• List patients for transplantation as this is often the only life-saving option 2

Organ System Management

Central Nervous System Management

• Monitor encephalopathy frequently and maintain serum sodium levels between 140-145 mmol/L to prevent cerebral edema 1
• Perform tracheal intubation and sedation for progressive hepatic encephalopathy (Glasgow < 8) 3, 1
• Avoid benzodiazepines and psychotropic drugs like metoclopramide 3, 1
• Position patient with head elevated at 30 degrees and minimize stimulation 2

Cardiovascular Support

• Assess volume status, cardiac output, and cardiac function 1, 5
• Use crystalloid fluids as first choice for fluid expansion 3, 1
• Administer norepinephrine for refractory hypotension to maintain mean arterial pressure of 50-60 mm Hg 3, 5
• Consider pulmonary artery catheterization in hemodynamically unstable patients 2, 5

Metabolic Management

• Monitor blood glucose at least every 2 hours and administer continuous glucose infusions for hypoglycemia 3, 1
• Monitor and supplement phosphate, magnesium, and potassium levels as needed 2
• Initiate enteral feedings early with moderate protein intake (approximately 60 grams per day) 2, 5

Coagulation Management

• Administer vitamin K 2
• Reserve fresh frozen plasma for invasive procedures or active bleeding rather than routine correction of coagulopathy 1, 2
• Give platelets for counts <10,000/mm³ or before invasive procedures 2

Renal Support

• Avoid nephrotoxic drugs, including NSAIDs 3, 1
• Use continuous rather than intermittent modes of renal replacement therapy if needed for acute renal failure 3, 2

Infection Prevention and Management

• Administer empirical broad-spectrum antibiotics to patients with worsening hepatic encephalopathy or signs of SIRS 1, 5
• Provide stress ulcer prophylaxis with H2 blockers or proton pump inhibitors 2, 5
• Perform periodic surveillance cultures to detect bacterial and fungal infections early 5

Liver Transplantation

• Contact transplant center early for patients with poor prognostic indicators 1, 2
• Consider urgent liver transplantation when prognostic indicators suggest high likelihood of death 2
• Poor prognostic indicators include idiosyncratic drug injury, non-hepatitis A viral infections, autoimmune hepatitis, mushroom poisoning, Wilson disease, Budd-Chiari syndrome, or indeterminate cause 2
• For acetaminophen-induced ALF, consider transplantation for arterial pH <7.3 after adequate volume resuscitation, or PT >100 seconds with serum creatinine >3.4 mg/dL in patients with grade III/IV coma 1, 2
• For non-acetaminophen ALF, consider transplantation for PT >100 seconds irrespective of coma grade 1, 2

Liver Support Systems

• Various liver support systems have been tested but show no certain evidence of efficacy 2
• Sorbent systems may provide transient improvement of hepatic encephalopathy but no improvement in long-term outcomes 2
• Bioartificial liver support may be considered as a bridge to transplantation, though further research is needed 2