Grade 1,ii rare Grade iii 25-35% Grade iv 65-75% Cerebral oedema most common cause of death.
In america ALFSG index used which includes patient gcs,bilrubin,inr,sr phosphorus,and sr M30 (ELISA based marker of apoptosis)..Limited use as M30 not available everywhere.Better prognostic indicator than KCC.
Improved mortality due to orthoptic liver transplant and better critical care. Research difficult due to rare and heterogenous nature with rapidly progressive course but result from application of other research e.g from cerebral edema management has improved mortality.
Reduces IL 17 levels in Non paracetamol ALF pts. In pcm overdose replinishes glutathione stores and detoxifies NAPQ1 highly reactive,toxic metabolite of paracetamol overdose.
Most common cause of death-cerebral oedema.
20_25% deaths in ALF due to intracranial hypertention and BS herniation. HE four compatible theories
Cerebral vasomotor dysfunction Oedema secondary to ammonia toxicity Inflammation due to SIRS putative benzodiazepine-like molecules
Complication rate with ICP monitor 3.8%,fatal haemorrhage 1%
Common organisms growing klebsiella oxy, VRE, Enterococcus faecium.
Prophylactic antibiotics for greatest risk pts as mentioned above.
Acute liver failure in icu
Acute Liver failure
Case…Thursday evening call from AnE
Mr C.E. 56 Year old male.
Presenting complaint of
Background history, liver transplant 8yrs ago with
normal liver functions untill 20 days back.
Definition of Liver failure
“The abrupt loss of hepatocellular function in a patient
with previously normal liver function, the expression of
which includes coagulopathy and encephalopathy.”
AASLD…“Evidence of a coagulation abnormality
(INR>1.5) and mental alteration (encephalopathy) in a
patient without pre-existing cirrhosis and with an illness
of <26wks duration”
Death of a mass of hepatocytes.
Loss of vital synthetic and metabolic hepatic functions.
Sterile inflammatory condition leading to SIRS.
Aim of management is to halt progression from hepatic
impairment to MODS.
If under 35 years of age
Ceruloplasmin, Serum & urine copper
Anti HAV IgM
Anti HBc IgM/ Anti HBsAg
Autoimmune markers – ANA, ASMA, Ig levels
Amylase & lipase
•May improve circulatory function and oxygen delivery
•No improvement in overall survival but significant improvement in
transplant-free survival with encephalopathy grade 1-2.
Time to NAC administration important
Time in hrs Mortality (%)
•Now generally recommended for all patients with ALF
When to pick up the phone in
Any rise in INR
Good ICU housekeeping
Stress ulcer prophylaxis
No DVT prophylaxis
Blood glucose management
Electrolytes like phosphate and magnesium.
No correction of coagulopathy
Severe Vasodilatory shock
Optimise cardiac filling pressures
–Haemodynamics can be challenging to determine given
the disruptive effects of liver failure on the vasculature
Saline challenge, albumin.
Avoid if possible
Propofol/Remifentanyl is reasonable
–Elective intubation once in grade 3 encephalopathy
Rapid intubation technique
–Avoid spikes in ICP or decreased CPP
–Commonest site of sepsis
Acute lung injury/ARDS
–In one third of patients
Renal failure in 50%
Particularly common with paracetamol overdose
–Liver and renal metabolites
Maintenance of blood pressure
Prevention/treatment of sepsis
Judicious selection of drugs
Early use of renal replacement therapy
–Before fluid problems aggravate cardiovascular status and
–Better ammonia level management
Complications of acute liver failure
Two principles in management of
Raised ICP management
1st line Mannitol
2nd line Hyperventillation to PaCO2 25-35mmhg
3rd line Hypertonic saline, Hypothermia
4th line Barbiturates, Anticonvulsants
Other considerations Transplantation, total
•Infection is near-universal
–Failing liver results in failed host defences
–Infection precipitates MOSF, cerebral oedema
–Frequent cause of death
–Bacterial and fungal
–Gram negative organisms (52%) more frequent than
Gram-positive organisms (44%) and Candida Infection
Minimize invasive procedures, strict asepsis
Daily chest radiograph and surveillance cultures
Empiric broad spectrum antibiotics for those patients
at greatest risk:
–Grade 3-4 encephalopathy
–Any component of SIRS
–Planned transplantation (includes antifungals)
Increased INR present by definition
Thrombocytopenia present in up to 70%
TEG is reassuring
Is there bleeding diathesis?
Significant bleeding is uncommon: 5%
–Anticoagulant proteins decrease in parallel with coagulation
–Spontaneous intracranial haemorrhage is rare
Less clinically-significant bleeding may occur from several
Invasive procedures offer the greatest risk
Correcting coagulopathy before
Correction itself carries risks
–Aggravation of ICP
–Transfusion-related acute lung injury
–Thromboembolism (particularly with recombinant Factor
Commonly used goal of INR <1.5 untested, lacks scientific
Correction obscures underlying trends in INR which are
Correcting coagulopathy before
FFP not encouraged except to correct coagulopathy before invasive procedure
–Effect modest, short-lived
–Does not improve survival
Recombinant activated Factor VII
MARS.. Extracorporeal support, dialysis against albumin.
CRRT against albumin.
Accepted Indications Absolute contraindications
Acute Liver Failure Brainstem herniation
Decompensated cirrhosis with
Severe intracranial hypertention
Hepatocellular criteria with Milan
unstability,requiring high dose
Hilar cholangiocarcinoma Uncontrolled infection
Hepatopulmonary syndrome Multiorgan failure
Portopulmonary hypertention Current/Recent extrahepatic
malignancy unless tumour
Primary hyperoxaluria Untrated alcoholism/Drug use
Cystic fibrosis with liver
Severe uncontrolled mood