UMEM Educational Pearls

Category: Critical Care

Title: Acute liver failure

Posted: 3/15/2022 by Duyen Tran, MD (Updated: 5/16/2022)
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Acute liver failure is defined as new and rapidly evolving hepatic dysfunction associated with neurologic dysfunction and coagulopathy (INR >1.5). Most common cause of death in these patients are multiorgan failure and sepsis. Drug-induced liver injuy most common cause in US, with viral hepatitis most common cause worldwide.

Management of complications associated with acute liver failure

  • Hepatic encephlopathy: Administer lactulose orally or via enema if risk of aspiration. Goal is to slow progression to severe encephalopathy and minimize development of cerebral edema.
  • Coagulopathy: Reverse if significant bleeding or if patient needs to have invasive procedure. FFP and 4-factor PCC not indicated in absence of bleeding. Additionally these patients may be vitamin-K deficient for which vitamin K can be given.
  • Consider empiric antibiotics due to increased susceptibility to infection.
  • Renal dysfunction: correct hypovolemia with fluid resuscitation. May require RRT, continuous preferred for hemodynamic stability.
  • If persistent hypotension despite adequate volume resuscitation and pressors, IV hydrocortisone indicated as adrenal insufficiency is common in these patients.
  • Early consultation with liver transplant center. King's College Criteria and MELD score are most commonly used prognostic tools.

References

Montrief T, Koyfman A, Long B. Acute liver failure: A review for emergency physicians. Am J Emerg Med. 2019 Feb;37(2):329-337. doi: 10.1016/j.ajem.2018.10.032. Epub 2018 Oct 22. PMID: 30414744.