Acute Liver Failure

• ALF = INR ≥1.5 plus encephalopathy in acute injury; give IV N-acetylcysteine for acetaminophen ALF and consider it in early non-acetaminophen ALF (150→50→100 mg/kg protocol).
• Expect constant hypoglycemia — run 10% dextrose + q1–2 h glucose checks; ammonia >150 → ICP threat (hypertonic saline, head-up, minimize stimulation).
• King's College criteria → transplant center EARLY; FFP only for bleeding/procedures.
• Grade III–IV encephalopathy requires intubation for airway protection.
• CRRT is recommended for ammonia >150 µmol/L even in stable patients; do NOT correct INR prophylactically — it is a prognostic marker.

Treating Acute Liver Failure

• Acute liver failure = INR ≥1.5 plus encephalopathy from acute liver injury in someone without prior cirrhosis — West Haven grade 1 or 2 → give NAC
• Acetaminophen: activated charcoal 1 g/kg (within 1–4 hrs); toxic nomogram levels or high suspicion within 48 hrs → cannot take PO: NAC IV load 150 mg/kg in D5%, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours; tolerates PO: NAC load 140 mg/kg, then 70 mg/kg PO q4 hours × 17 doses
• Other causes — drug-induced hypersensitivity → consider corticosteroids only for selected immune-mediated drug reactions or autoimmune hepatitis · acute ischemic injury → support perfusion · acute hepatitis B → consider an antiviral · autoimmune hepatitis → prednisone 40–60 mg/d · Wilson's disease → urgent transplant evaluation; chelate with D-penicillamine 250–500 mg/d or trientine 750–1500 mg/d in three divided doses · herpes virus → acyclovir · mushroom poisoning → urgent transplant evaluation; gastric lavage plus activated charcoal (1 g/kg); penicillin 300K–1 million IU/kg/d; silibinin/silymarin 30–40 mg/kg/d IV or orally

Central Nervous System Complications of Acute Liver Failure

• General measures: head CT to exclude hemorrhage · head of bed up 30 degrees, avoid Valsalva, minimize stimulation, sedate · grade III–IV encephalopathy → intubate
• Raised intracranial pressure? (ICP monitoring: ICP >20–25, CPP <50–60 · irregular respirations, dilated pupils, decerebrate posturing, Cushing's reflex)
• Invasive ICP monitoring an option (use conventional blood products for placement; recombinant FVIIa is not recommended). Target ICP <20–25 mm Hg, CPP >50–60 mm Hg
• MANNITOL: bolus 0.5–1 g/kg, repeatable twice at 4–6 hour intervals — no proven prophylactic role; hold serum osmolality <320 mOsm/kg; side effects: hypernatremia, volume overload
• HYPERTONIC SALINE: 3% NaCl infusion (or 23.4% saline 30 mL bolus via central line), titrated to serum sodium 145–155 mmol/L
• SEDATION: infuse propofol; alternatives thiopental, pentobarbital — barbiturate side effects: severe hypotension, prolonged sedation
• HYPERVENTILATION: set respiratory rate to pCO₂ 25–30 mm Hg for acute control of refractory ICH — a temporary measure; no proven prophylactic role
• BODY TEMPERATURE: treat fever; allow spontaneous core temperatures of 35–36°C — induced hypothermia has no proven benefit

Managing the Complications of Fulminant Hepatic Failure

• Complications — HYPOTENSION: albumin or saline → MAP still <65 mm Hg → norepinephrine (preferred), adding vasopressin when needed → D5%-based maintenance fluids
• COAGULOPATHY — prophylaxis: proton pump inhibitors; hold platelets until platelets <10 k · bleeding: local measures; vitamin K 5–10 mg IV; transfuse FFP and platelets as indicated · planned procedure: transfuse platelets to >50 k; recombinant FVIIa is not recommended outside trial settings
• INFECTION: send surveillance cultures; low threshold for prophylactic broad-spectrum antibiotics; bowel decontamination has no role
• RENAL: fluid challenge; avoid nephrotoxins → failure worsening? → CVVHD preferred over HD
• METABOLIC: start early enteral or parenteral nutrition; replete electrolytes; replete glucose
• CNS: → Pathway 59.2 (intracranial pressure management)