The Korean Journal of Gastroenterology :eISSN 2233-6869 / pISSN 1598-9992


Table. 2.

Management of Patients with Acute Liver Failure

A. Routine monitoring and basic care
(1) Transfer to intensive care unit or transplant center
(2) Apply multimonitoring – blood pressure, electocardiography, respiratory rate, oxygen saturation
(3) Catheterization – central vein, Foley catheter±nasogastric tube
(4) Check-up of intake, urinary output & stool passage
(5) Peptic ulcer prevention – H2 blocker (preferred), proton pump inhibitor
(6) Thromboprophylaxis – graduated compression stockings or intermittent pneumatic compression
B. Neurologic
(1) Position – head of bed elevation (20-30 degrees)
(2) Brain imaging – CT scan±diffusion-weighted MRI
(3) Assessment of level of consciousness and grade of encephalopathy - pupil light reflex (hourly), Glasgow coma scale (q 2-4 hours), optionally, cEEG, ONSD, TCD±intracranial pressure monitoring
(4) Intubation with sedation and mechanical ventilation (in case of grade 3-4 encephalopathy)
(5) Medication - mannitol (only a limited number of times)
(6) Consider hypertonic saline (target serum sodium 145-155 mEq/L)±moderate hypothermia (core body temperature 34-35℃) in refractory patients
C. Hemodynamic
(1) Maintain blood pressure (MAP ≥75 mmHg) via volume replacement and/or vasoactive drugs (norepinephrine±terlipressin)
(2) Transthoracic echocardiography – initially and in case of uncorrectable hypotension
(3) Check adrenal function in sustained hypotensive patients
D. Metabolic
(1) Check-up of BST (q 2 hours) and glycemic control (maintain glucose >150 mg/dL)
(2) Nutritional support – total parenteral nutrition with continuous dextrose IV (if enteral feeding is impossible)
(3) Support renal function using CRRT – correction of volume overload, oligo-anuria, acidosis, hyperammonemia, etc.
(4) Balancing of electrolytes (sodium, potassium, chloride) and minerals (phosphate, magnesium, calcium)
E. Infectious
(1) Initial and surveillance cultures (blood, urine, sputum)
(2) Appropriate antibiotics if indicated
F. Etc.
(1) Disease-specific therapies – N-acetylcysteine (in early phase of AAP overdose), penicillin G+silymarin (in mushroom poisoning), corticosteroid (in autoimmune hepatitis), antiviral agents (in HBV, HSV, VZV infection)
(2) Consider therapeutic plasma exchange (for bridging therapy to LT or inoperable patients)
(3) Avoid routinely blood transfusion
(4) Avoid hepatotoxic or nephrotoxic agents

cEEG, continuous electroencephalography; ONSD, optic nerve sheath diameter; TCD, transcranial Doppler; MAP, mean arterial pressure; BST, blood sugar test; IV, intravenous; CRRT, continuous renal replacement therapy; AAP, acetaminophen; ALF, acute liver failure; HSV, Herpes simplex virus; VZV, Varicella zoster virus; LT, liver transplantation.

Korean J Gastroenterol 2023;81:17~28
© Korean J Gastroenterol