Selecting a Treatment Regimen
Table 4. Intensive Care of Acute Liver Failure
Cerebral Edema/Intracranial Hypertension
Grade I/II Encephalopathy
Consider transfer to liver transplant facility and listing for transplantation
Brain CT: rule out other causes of decreased mental status; little utility to identify
cerebral edema
Avoid stimulation; avoid sedation if possible
Antibiotics: surveillance and treatment of infection required; prophylaxis possibly
helpful
Lactulose, possibly helpful
Grade III/IV Encephalopathy
Continue management strategies listed above
Intubate trachea (may require sedation)
Elevate head of bed
Consider placement of ICP monitoring device
Immediate treatment of seizures required; prophylaxis of unclear value
Mannitol: use for severe elevation of ICP or first clinical signs of herniation
Hypertonic saline to raise serum sodium to 145-155 mmol/L
Hyperventilation: effects short-lived; may use for impending herniation
Infection
Surveillance for and prompt antimicrobial treatment of infection required
Antibiotic prophylaxis possibly helpful but not proven
Coagulopathy
Vitamin K: give at least one dose
FFP: give only for invasive procedures or active bleeding
Platelets: give only for invasive procedures or active bleeding
Recombinant activated factor VII: possibly effective for invasive procedures
Prophylaxis for stress ulceration: give H2 blocker or PPI
Hemodynamics/Renal Failure
Volume replacement
Pressor support (dopamine, epinephrine, norepinephrine) as needed to maintain
adequate mean arterial pressure
Avoid nephrotoxic agents
Continuous modes of hemodialysis if needed
Vasopressin recommended in hypotension refractory to volume resuscitation and
norepinephrine
Metabolic Concerns
Follow closely: glucose, potassium, magnesium, phosphate
Consider nutrition: enteral feedings if possible or total parenteral nutrition
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