Management of Post-Hepatectomy Liver Failure
Post-hepatectomy liver failure requires immediate intensive supportive care focused on hemodynamic stabilization, aggressive infection control, metabolic support, and early transplant evaluation—with liver transplantation offering 78% one-year survival compared to less than 10% without transplant in severe cases. 1
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. 2, 3
Grade severity using the ISGLS system: 2, 3
- Grade A: Laboratory abnormalities only, no clinical impact
- Grade B: Requires deviation from standard postoperative care
- Grade C: Requires intensive care support
Reassess SOFA score at 48-72 hours and day 7 rather than relying on admission values—delta SOFA and persistence of 3-4 organ failures at day 3-7 predict mortality with 93-100% specificity. 1
Immediate Hemodynamic Management
Maintain mean arterial pressure ≥50-60 mmHg through aggressive fluid resuscitation followed by vasopressor support if needed. 2
Use albumin (colloid) as first-line fluid resuscitation rather than crystalloid, with all solutions containing dextrose to maintain euglycemia. 2
If vasopressors are required, use epinephrine, norepinephrine, or dopamine—specifically NOT vasopressin. 2
Infection Prevention and Treatment
Administer empirical broad-spectrum antibiotics immediately if there are signs of worsening encephalopathy or systemic inflammatory response syndrome (SIRS)—do not wait for culture results. 1, 2
Bacterial infections occur in 60-80% of acute liver failure patients, and infection is the most common precipitant of deterioration. 1, 2
Consider fungal coverage with persistent fever despite antibacterial therapy, as fungal infections occur in one-third of patients. 2
Perform surveillance cultures periodically (sputum, urine, blood) to detect infections early and adjust therapy accordingly. 1
Metabolic and Nutritional Support
Monitor blood glucose at least every 2 hours and maintain normoglycemia (<8.3 mmol/L) with continuous glucose infusions and insulin therapy as needed. 1, 2
Implement early oral intake with normal diet immediately—do not delay feeding. 1, 2, 3
Reserve enteral or parenteral nutrition only for: 1, 2, 3
- Malnourished patients
- Patients with complications causing prolonged fasting
- Patients with underlying cirrhosis
Maintain serum sodium between 140-145 mmol/L through careful monitoring. 2
Encephalopathy Management
Intubate and sedate if progressive hepatic encephalopathy with Glasgow Coma Scale <8, minimizing sedation depth and avoiding benzodiazepines and psychotropic drugs. 2
Elevate head to 30 degrees in patients progressing to grade III or IV encephalopathy. 1
Treat seizure activity with phenytoin and low-dose benzodiazepines. 1
Lactulose may be used in early stages, though concern exists about increasing bowel distention if transplant becomes necessary. 1
Renal Support
Use continuous renal replacement therapy rather than intermittent hemodialysis if dialysis is needed for acute renal failure. 2
Coagulation Management
Do NOT routinely correct coagulation abnormalities—restrict clotting factor administration to active bleeding or high-risk invasive procedures only. 2, 4
Traditional coagulation tests (INR, PT) overestimate bleeding risk and do not reliably predict procedural bleeding in liver failure. 4
Thromboprophylaxis
Start low molecular weight heparin or unfragmented heparin postoperatively unless exceptional circumstances make this unsafe. 2, 3
Add intermittent pneumatic compression devices to further decrease thrombotic risk. 2
Stress Ulcer Prophylaxis
Provide stress ulcer prophylaxis with H2 blocking agents or proton pump inhibitors. 2
Liver Transplantation Evaluation
Refer immediately to a transplant center when prognostic indicators suggest high likelihood of death—the "transplantation window" is often narrow in these patients. 1, 2
Post-transplant survival rates for acute liver failure are 80-90%, with early transplant offering 78% one-year survival compared to less than 10% without transplant. 1, 2
Rapid decision-making by a multidisciplinary specialized team is essential as patients with ACLF grade >2 benefit significantly from early transplantation. 1
Artificial Liver Support Systems
Albumin dialysis systems (MARS, Prometheus) showed improvement in hepatic encephalopathy and hepatorenal syndrome in post-hoc analyses, though randomized trials did not demonstrate survival benefit at 28-90 days. 1
Consider artificial liver support as "bridge to transplant" in patients with ACLF and multiple organ failure, where observational data suggest improved short-term survival (14-28 days) allowing access to transplantation. 1
Critical Pitfalls to Avoid
Do NOT delay empirical antibiotics while awaiting culture results—infection must be treated immediately as it is the most common precipitant of deterioration. 1, 2
Do NOT use growth factors for leukopenia—there is no evidence for this approach in liver failure. 2
Do NOT routinely correct coagulation unless active bleeding is present—this does not reduce bleeding risk and may increase complications. 2, 4
Do NOT rely on INR/PT values to predict bleeding risk—these parameters overestimate coagulopathy after hepatectomy. 4
Do NOT administer excessive crystalloid fluids—this can be as harmful as blood loss during liver surgery. 4