Coagulopathy and Bleeding
ÎPrescribe replacement therapy for thrombocytopenia and/or prolonged prothrombin time only in the setting of hemorrhage or prior to invasive procedures (III).
ÎFor patients with ALF in the ICU, give prophylaxis with H2 Hemodynamics and Renal Failure
ÎOrder 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).
ÎIf dialysis support is needed for acute renal failure, use a continuous mode rather than an intermittent mode (I).
ÎPulmonary 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).
ÎAdminister 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).
ÎGoals of circulatory support in patients with ALF are a MAP ≥ 75 mmHg and CPP 60-80 mmHg (II).
Metabolic Concerns
ÎCarefully 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
ÎCurrently 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).
ÎUrgent hepatic transplantation is indicated in acute liver failure where prognostic indicators suggest a high likelihood of death (II-3).
ÎConsider living donor or auxiliary liver transplantation in the setting of limited organ supply, but its use remains controversial (II-3).
ÎCurrently available liver support systems are not recommended outside of clinical trials. Their future in the management of acute liver failure remains unclear (II-1).
blocking
agents or proton pump inhibitors (or sucralfate as a second-line agent) for acid-related gastrointestinal bleeding associated with stress (I).
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