ALF = INR ≥1.5 plus encephalopathy within 26 weeks of acute injury, without known cirrhosis; give IV N-acetylcysteine for acetaminophen ALF and consider it in early non-acetaminophen ALF (150→50→100 mg/kg protocol).
Check glucose q1–2 h; titrate 10% dextrose if needed to keep 110–180 mg/dL. Ammonia >150 µmol/L signals cerebral-edema risk: head up, minimize stimulation and consider hypertonic saline with specialist monitoring.
Contact the transplant center as soon as ALF is suspected; do not wait for King’s College criteria. Avoid prophylactic FFP; use blood products for bleeding or selected procedure-related needs.
Grade III–IV encephalopathy requires intubation for airway protection.
Consider early CRRT for marked/rising hyperammonemia (e.g., >150 µmol/L) or significant encephalopathy, even without conventional renal indications; individualize with the transplant/ICU team. Do not correct INR prophylactically — it is a prognostic marker.
Investigations
First tests: Liver biochemistry, PT/INR, Blood glucose, Sodium, potassium, bicarbonate, urea and creatinine, Paracetamol/acetaminophen concentration.
Only if indicated: Etiology-directed liver failure tests, Liver ultrasound with Doppler, Ammonia.
Repeat monitoring: PT/INR.
Management pathways in this chapter
Treating Acute Liver Failure
Central Nervous System Complications of Acute Liver Failure
Managing the Complications of Fulminant Hepatic Failure
Locked
Each pathway step by step, with its decision points
ICU Decoded — original critical-care and internal-medicine pathways by
Dr Javed Akhtar, each cited to a current guideline. For education and quick
reference; verify every dose against local protocols before prescribing.