Management of Post-Hepatectomy Liver Failure
Post-hepatectomy liver failure (PHLF) requires immediate intensive care admission with aggressive supportive management focused on hemodynamic stabilization, infection prevention, metabolic support, and early consideration for liver transplantation, as there is no specific curative treatment available. 1, 2
Diagnosis and Severity Assessment
Apply the 50-50 criteria on postoperative day 5: prothrombin time index <50% AND serum bilirubin >50 μmol/L, which predicts 59% mortality risk versus 1.2% when criteria are not met. 1, 3
Grade severity using the ISGLS system: 1, 3
- Grade A: Laboratory abnormalities only, no clinical impact
- Grade B: Requires deviation from standard postoperative care
- Grade C: Requires intensive care support
Core Management Strategy
Hemodynamic Support (First Priority)
Maintain mean arterial pressure ≥50-60 mmHg through aggressive fluid resuscitation. 1
Use colloid (albumin) rather than crystalloid as first-line fluid, with all solutions containing dextrose to maintain euglycemia. 1
If fluid replacement fails to maintain adequate MAP, use epinephrine, norepinephrine, or dopamine as vasopressors (NOT vasopressin). 1
Infection Prevention and Treatment (Critical)
Administer empirical broad-spectrum antibiotics immediately if there are signs of worsening encephalopathy or systemic inflammatory response syndrome. 1
Do not delay antibiotics while awaiting culture results—bacterial infections occur in 60-80% of acute liver failure patients and infection is the most common precipitant of death. 1
Consider fungal coverage with persistent fever despite antibacterial therapy, as fungal infections occur in one-third of patients. 1
Metabolic and Nutritional Management
Monitor blood glucose at least every 2 hours and maintain normoglycemia with continuous glucose infusions and insulin therapy. 1
Implement early oral intake with normal diet immediately after hepatectomy, reserving enteral or parenteral feeding only for malnourished patients or those with prolonged fasting due to complications. 1, 3
Coagulation Management
Do not routinely correct coagulation abnormalities—restrict clotting factor administration to active bleeding or high-risk invasive procedures only. 1
Administer vitamin K to all patients, but reserve fresh frozen plasma for active bleeding situations. 4
Encephalopathy Management
Monitor encephalopathy frequently and maintain serum sodium between 140-145 mmol/L. 1
Perform tracheal intubation and sedation if progressive hepatic encephalopathy with Glasgow Coma Scale <8, minimizing depth of sedation and avoiding benzodiazepines and psychotropic drugs. 1
Renal Support
Use continuous renal replacement therapy rather than intermittent hemodialysis if dialysis is needed for acute renal failure. 1
Additional Supportive Measures
Provide stress ulcer prophylaxis with H2 blocking agents or proton pump inhibitors. 1
Start low molecular weight heparin or unfragmented heparin postoperatively unless exceptional circumstances make this unsafe, and add intermittent pneumatic compression devices. 1, 3
Liver Transplantation Consideration
Refer urgently to a transplant center when prognostic indicators suggest high likelihood of death, as the "transplantation window" is often narrow. 1
Post-transplant survival rates for acute liver failure are 80-90%, making early referral critical. 1, 4
Critical Pitfalls to Avoid
Do not use growth factors for leukopenia—there is no evidence for this approach in liver failure. 1
Do not routinely correct coagulation unless active bleeding is present, as this wastes resources without improving outcomes. 1
Do not delay empirical antibiotics—sepsis is the leading cause of mortality in PHLF and must be treated immediately. 1
Pathophysiology Context
The pathophysiology of PHLF is difficult to reverse once established, which is why management is primarily supportive. 5, 2 The vast majority of mortality is related to sepsis, organ failure, and cerebral events rather than liver failure itself. 2 Despite multiple attempts, there has been little progress in definitive and specific management of liver failure beyond supportive care. 2, 6