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,