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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