Acute Liver FailureICU / resuscitation

Paracetamol overdose 2 days ago, now INR 3.8, confused, glucose 2.1 — INR ≥1.5 + encephalopathy = acute liver failure. NAC for everyone, transplant call early.

• INR rising over days, not hours
• Confusion/agitation (grade II)
• Glucose <54 mg/dL repeatedly
• NH₃ >150 µmol/L (255 µg/dL)

• Paracetamol (commonest in UK/US)
• Viral hepatitis A/B/E
• Autoimmune, Wilson, Budd-Chiari
• DILI (isoniazid, herbals), mushroom poisoning

• Admit: All ALF → ICU/HDU, transplant centre if criteria approached
• NAC: Every ALF patient regardless of cause
• Intubate: Grade III–IV encephalopathy, agitation, ICP signs

• Phosphate paradox: LOW phosphate = liver regenerating well; HIGH = massive necrosis, poor prognosis
• Avoid NSAIDs, sedatives, and protein loads; lactulose has NO role in ALF encephalopathy
• Hypoglycaemia + rising INR + rising NH₃ = the triad that phones the transplant centre

• Give FFP to 'correct' the INR unless bleeding or a procedure — you destroy the best prognostic marker
• Sedate before grading encephalopathy — masks deterioration
• Wait for a paracetamol level before starting NAC

• Stopping NAC at 21 h while still acidotic/encephalopathic (continue until improving)
• Normal paracetamol level = false reassurance at late presentation
• Prophylactic FFP
• Missing hypoglycaemia as the cause of 'encephalopathy worsening'
• Choosing intermittent HD over CRRT when NH₃ >150 µmol/L (255 µg/dL)

ICU + early transplant centre liaison; if survives with native liver — full recovery usual; psychiatry follow-up after overdose; vaccinations vs triggers.