Treatment
����In early stages of encephalopathy, use lactulose either orally or
rectally to effect a bowel purge, but it should not be administered
to the point of diarrhea and may interfere with the surgical field by
increasing bowel distention during liver transplantation (III).
����Patients who progress to high-grade hepatic encephalopathy (grade III
or IV) should undergo endotracheal intubation (III).
����Treat seizure activity with phenytoin and benzodiazepines with short
half-lives. Prophylactic phenytoin is NOT recommended (III).
����Monitor intracranial pressure (ICP) in ALF patients with high grade
hepatic encephalopathy, in centers with expertise in ICP monitoring,
in patients awaiting and undergoing liver transplantation (III).
����In the absence of ICP monitoring, perform frequent (hourly)
neurological evaluation to identify early evidence of intracranial
hypertension (III).
����In the event of intracranial hypertension, give a mannitol bolus
(0.5-1.0 gm/kg body weight) as first-line therapy. However, the
prophylactic administration of mannitol is NOT recommended (II-2).
����In ALF patients at highest risk for cerebral edema ��� serum ammonia
> 150 ��M, grade 3/4 hepatic encephalopathy, acute renal failure,
vasopressors required to maintain mean arterial pressure (MAP) ���
induce hypernatremia prophylactically with hypertonic saline to a
sodium level of 145-155 mEq/L (I).
����Consider short-acting barbiturates and the induction of hypothermia
to a core body temperature of 34-35��C for intracranial hypertension
refractory to osmotic agents as a bridge to liver transplantation (II-3).
����Do NOT use corticosteroids to control elevated ICP in patients with
ALF (I).
Infection
����Collect periodic surveillance cultures to detect bacterial and fungal
pathogens as early as possible. Initiate antibiotic treatment promptly
according to surveillance culture results at the earliest sign of
active infection or deterioration ��� progression to high grade hepatic
encephalopathy or elements of the systemic inflammatory response
syndrome (SIRS) (III).
����Prophylactic antibiotics and antifungals have not been shown to
improve overall outcomes in ALF and therefore cannot be advocated in
all patients, particularly those with mild hepatic encephalopathy (III).
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