Treatment
ÎIn 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).
ÎPatients who progress to high-grade hepatic encephalopathy (grade III or IV) should undergo endotracheal intubation (III).
ÎTreat seizure activity with phenytoin and benzodiazepines with short half-lives. Prophylactic phenytoin is NOT recommended (III).
ÎMonitor 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).
ÎIn the absence of ICP monitoring, perform frequent (hourly) neurological evaluation to identify early evidence of intracranial hypertension (III).
ÎIn 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).
ÎIn ALF patients at highest risk for cerebral edema – serum ammonia > 150 µM, 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).
ÎConsider 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).
ÎDo NOT use corticosteroids to control elevated ICP in patients with ALF (I).
Infection
ÎCollect 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).
ÎProphylactic 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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