Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
intensive care management
Patients with ALF with grade 2 or higher hepatic encephalopathy should be admitted to an intensive care unit (ICU).[4] The natural history of ALF may be characterised by a rapid deterioration in neurological status, high risk of complications including sepsis and cerebral oedema, haemodynamic instability, and renal failure. Intensive care unit monitoring is critical in providing optimal care of the patient and to prevent and treat known complications of ALF.
Efforts should be made to minimise elevations of intracranial pressure. The head of the patient's bed should be raised to approximately 30 degrees and surrounding stimuli reduced to a minimum.[51] Once advanced encephalopathy develops (grades 3 or 4), tracheal intubation should be performed for airway protection.[4] Propofol and fentanyl are preferred agents for analgesia and sedation due to their short half-lives. Intravenous fluids should be administered with caution to prevent depletion or volume overload; central venous pressure and pulmonary arterial monitoring as well as renal replacement therapy should be considered early to ensure optimal fluid management, particularly if there is evidence of renal or circulatory dysfunction.[8][100]
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
Enteral nutrition is generally a concern in the setting of encephalopathy, in which the patient is unable to obtain adequate nutrition due to an altered mental status. Therefore, enteral nutritional support with calorie-dense feeds should also be initiated early during the hospital course.
Prophylactic antimicrobial therapy does not appear to influence outcome and is not recommended.[4][104] However, empirical antimicrobials are recommended if a patient develops positive surveillance cultures, refractory hypotension, progression to grade 3 to 4 hepatic encephalopathy, evidence of Systemic Inflammatory Response Syndrome; and in all patients who are listed for liver transplantation.[100]
Proton-pump inhibitors or H2 antagonists should be administered as prophylaxis of gastrointestinal bleeding secondary to coagulopathy.[8]
liver transplantation assessment
Treatment recommended for ALL patients in selected patient group
Criteria for United Network for Organ Sharing (UNOS) Status 1A designation include: age >18 years, life expectancy without a liver transplant of <7 days, onset of encephalopathy within 8 weeks of the first symptoms of liver disease, absence of pre-existing liver disease, admission to an intensive care unit, and 1 of the following: ventilator dependence, requirement of renal replacement therapy, or INR >2.0. UNOS status 1A patients are listed with top priority for liver allocation. Wilson's disease may also be given Status 1A priority.
Contraindications to liver transplantation include severe cardiac or pulmonary disease, AIDS, extrahepatic malignancy, metastatic hepatocellular carcinoma, intrahepatic cholangiocarcinoma, uncontrolled sepsis, irreversible neurological complications (e.g., brain death, intracerebral haemorrhage, intractable sustained raised intracranial pressure), ongoing alcohol or illicit substance misuse, and lack of an adequate social support system.[48]
Ultrasound-guided insertion of a non-tunnelled central venous catheter (CVC) into the right internal jugular vein using the Seldinger insertion technique.
neurological status monitoring for advanced encephalopathy
Treatment recommended for ALL patients in selected patient group
Neurological status should be monitored carefully and regularly for the development of advanced encephalopathy (grade 3 to 4), which is associated with a greater risk of cerebral oedema and intracranial hypertension.
Head of the patient's bed should be raised to 30 degrees and surrounding stimuli reduced. Tracheal intubation and sedation with intravenous propofol or fentanyl should be performed once advanced encephalopathy develops. Central venous pressure monitoring, pulmonary arterial monitoring, and renal replacement therapy should be considered early.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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