Coagulopathy and Bleeding
����Prescribe replacement therapy for thrombocytopenia and/or
prolonged prothrombin time only in the setting of hemorrhage or prior
to invasive procedures (III).
����For patients with ALF in the ICU, give prophylaxis with H2 blocking
agents or proton pump inhibitors (or sucralfate as a second-line agent)
for acid-related gastrointestinal bleeding associated with stress (I).
Hemodynamics and Renal Failure
����Order fluid resuscitation and maintenance of adequate intravascular
volume on presentation in patients with ALF. The initial treatment of
hypotension should be with intravenous normal saline (III).
����If dialysis support is needed for acute renal failure, use a continuous
mode rather than an intermittent mode (I).
����Pulmonary artery catheterization is rarely necessary in patients with
ALF and is associated with significant morbidity. Instead, ensure
appropriate volume status with a volume challenge (III).
����Administer systemic vasopressor support with agents such as
norepinephrine in volume-refractory hypotension or to ensure
adequate cerebral perfusion pressure (CPP). Add vasopressin or
terlipressin to norepinephrine in norepinephrine-refractory cases, but
use these agents cautiously in severely encephalopathic patients with
intracranial hypertension (II-1).
����Goals of circulatory support in patients with ALF are a MAP ��� 75 mmHg
and CPP 60-80 mmHg (II).
Metabolic Concerns
����Carefully maintain metabolic homeostasis in ALF patients. Monitor
overall nutritional status as well as glucose, phosphate, potassium
and magnesium levels frequently, with expeditious correction of
derangements (III).
Prognosis and Transplantation
����Currently available prognostic scoring systems do not adequately
predict outcome and determine candidacy for liver transplantation.
Reliance entirely upon these guidelines is thus NOT recommended (III).
����Urgent hepatic transplantation is indicated in acute liver failure where
prognostic indicators suggest a high likelihood of death (II-3).
����Consider living donor or auxiliary liver transplantation in the setting of
limited organ supply, but its use remains controversial (II-3).
����Currently available liver support systems are not recommended
outside of clinical trials. Their future in the management of acute liver
failure remains unclear (II-1).
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