2. DEFINATION
• According to PALF the defination of ALF includes
1) Hepatic based coagulopathy with inr > or equal to 1.5 or PT
greater or equal to 15 not corrected by vitamin k in presence
with clinical hepatic encephalopathy
OR
2) INR more than 2 or PT more than 20 regardless of
presence of clinical hepatic encephalopathy
ALONG WITH biochemical evidence of liver injury and no
chronic liver disease
3. ETIOLOGY OF ACUTE LIVER FAILURE
• VARIES ACCORDING TO AGE AND GEOGRAPHICAL
LOCATION.
• THE MOST COMMON CAUSE OF ALF IN CHILDREN IN
INDIA IS VIRAL HEPATITIS
• THE MOST COMMON CAUSE OF ALF REQUIRING
LIVER TRANSPLANTATION IS WILSON DISEASE.
4. ETIOLOGY OF ALF
INFECTIVE
PRIMARY HEPATOTROPIC VIRUSES : HEPATITIS
A TO HEPATITIS E
INVESTIGATION
ANTI HAV IGM ANTIBODY
HBSAG ,HBCAB(IGM),HBCAG
ANTI-HEP C ANTIBODY,HEP C PCR
ANTI-HEP D ANTIBODY
ANTI HEV ANTIBODY(IGM)
SECONDARY HEPATOTROPIC VIRUSES
HERPES SIMPLEX VIRUS,CYTOMEGALOVIRUS,
EBSTEIN BAR
VIRUS,MEASLES/VARICELLA/ADENOVIRUS/DE
NGUE /ECHOVIRUS
POLYMERASE CHAIN REACTION (PCR)
SEROLOGY/PCR(BASED ON CLINICAL
SYNDROME)
BACTERIAL INFECTION
AUTOIMMUNE IMMUNOGLOBULINS
ANTI SMOOTH MUSCLE ANTIBODY
5. MANAGEMENT OF ACUTE LIVER
FAILURE
• MANAGEMENT OF ALF ENTAILS
• 1) IDENTIFYING ETIOLOGY OF ALF
• 2) ENSURING SUPPORTIVE THERAPY
• 3) EARLY REFERAL TO LIVER TRANSPLANT CENTRE
• 4) ANY BRIDGING THERAPY FOR OPTIMAL
OUTCOME
• 5) LIVER TRANSPLANT
6. GENERAL MEASURES IN ALF
• CHILDREN WITH ALF SHOULD BE MONITORED IN QUIET SETTING.
• VITAL PARAMETERS SUCH AS BLOOD PRESSURE,OXYGEN
SATURATION,PULSE,NEUROLOGICAL EVALUATION SHOULD BE
MADE ON REGULAR BASIS
• PROPHYLACTIC ANTIFUNGALS AND BROAD SPECTRUM
ANTIBIOTICS SHOULD BE STARTED IN ALL CHILDREN
• EMPERICAL ACYCLOVIR THERAPY IN NEONATES AND INFANTS.
• CHILDREN WITH INR GREATER THAN 4 OR ENCEPHALOPATHY
SHOULD BE ADMITTED IN PICU.
7. AIRWAY AND VENTILATION
• ELECTIVE INTUBATION AND MECHANICAL VENTILATION
SHOULD BE CONSIDERED IN PATIENTS WITH GRADE 1 OR 2
ENCEPHALOPATHY THAT ARE AGITATED AND IN ALL WITH
GRADE 3 AND 4.
• MECHANICAL VENTILATION HELPS IN REDUCING SUDDEN
VARIATION OF ICP
• INTUBATION BY EXPERIENCED PERSONEL IS ADVISED AS
AIRWAYS ARE DIFFICULT DUE TO COAGULOPATHY AND ICP
• MAINTAIN SPO2 > 94% AND PCO2 IN THE RANGE OF 35-
40MM HG.
• PEEP SHOULD BE AVOIDED AS IT CAN CAUSE INCREASE
VENOUS PRESSURE AND INTRACRANIAL PRESSURE.
8. FLUIDS AND ELECTROLYTES
• FLUIDS SHOULD BE RESTRICTED TO 2/3 RD
MAINTAINENCE.
• USE FLUID CONTAINING 10% DEXTROSE TO
MAINTAIN GLUCOSE INFUSION RATE IN THE RANGE
OF 4-6MG/KG/MIN TO AVOID HYPOGLYCEMIA.
• MAINTAIN SERUM SODIUM BETWEEN 145-150
MEQ/DL TO PREVENT CEREBRAL EDEMA. Might
require 3% nacl to achieve this.
9. HEMODYNAMICS
• THOSE WITH ALF ARE TYPICALLY VASODILATED AND
HAVE DECREASED INTRAVASCULAR VOLUME AND THIRD
SPACING AND HYPERDYNAMIC HEART FUNCTION
• JUDICIOUSLY RESUSCITATE WITH FLUIDS USING
VARIOUS HEMODYNAMIC INDICES SUCH AS INFERIOR
VENA CAVA COLLAPSIBILITY INDEX,LUNG ULTRASOUND
AND FUNCTIONAL ECHO.
• NOR-ADRENALINE IS THE FIRST CHOICE OF IONOTROPE
DUE TO PERIPHERAL VASOCONSTICTION PROPERTIES
10. COAGULOPATHY
• THOUGH CHILDREN WITH ALF HAVE DERANGED
COAGULATION,HEMOSTASIS APPEARS TO BE REBALANCED
AS BOTH PRO AND ANTI COAGULANTS ARE DEFICIENT IN
ALF
• VITAMIN K1 AND ACID REDUCING MEDICATIONS SUCH AS
PROTON PUMP INHIBITORS AND HISTAMINE H2 BLOCKERS
IS EMPERICALLY RECOMMENDED IN ALL PATIENTS WITH
ALF
• TRANSFUSION IS ONLY RESERVED FOR INVASIVE
PROCEDURES,IF THERE IS ACTIVE BLEEDING OR WHEN INR
IS >4 AND PATIENT HAS BEEN LISTED FOR TRANSPLANT.
11. RENAL SUPPORT
• ACUTE KIDNEY INJURY IN PATIENTS WITH HEPATIC
FAILURE MIGHT BE PRE RENAL(HYPOVOLEMIA) OR
SECONDARY TO ACUTE TUBULAR NECROSIS OR
HEPATORENAL SYNDROME.
• THE INDICATION FOR INITIATING RENAL
REPLACEMENT THERAPY ARE
• 1)renal cause
• 2)hyperammonia >150 mmol/dl
• 3)grade 3/4 hepatic encephalopathy
• 4) metabolic causes like resistant metablic
acidosis,hyponatremia
12. ANTIBIOTIC PROPHYLAXIS
• EMPERICAL ADMINISTRATION OF ANTIBIOTICS IS
RECOMMENDED IN ADVANCED STAGE (3/4)
HE,HYPOTENSION,SUSPECTED SEPSIS,POSITIVE
CULTURE AND THOSE POSTED FOR LIVER
TRANSPLANT.
• ALL PATIENTS TO BE STARTED ON ANTIFUNGALS AS
33% OF SEPSIS IN ALF ARE DUE TO CANDIDA
INFECTIONS
• ALL INFANTS WITH ALF SHOULD BE STARTED ON
ACYCLOVIR FOR 21 DAYS TILL PCR IS NEGATIVE
13. NEUROPROTECTIVE MEASURES
• NITROGENOUS ACCUMULATION SUCH AS
AMMONIA,CYTOKINE STORM ,ALTERED BLOOD BRAIN
BARRIER AND VASODILATORY STATE IS POSTULATED AS
REASON OF CEREBRAL EDEMA
• GENERAL MEASURES TO BE IMPLEMENTED IN ALL
PATIENTS WITH HEPATIC ENCEPHALOPATHY ARE-
• Head end of the bed to be elevated by 30 to 45 degrees
• Neck in neutral position
• Normothermia
• Normoxemia(pa02 >60 and spo2 > 94%)
• Normocarbia ( paco2 35-40 mm hg)
14. • Normoglycemia (100-180 mg/dl)
• Serum sodium should be maintained between 145-150
meq/l to reduce osmotic cerebral edema
• Cerebral perfusion pressure targeted therapy. maintain
between 40-50 mm hg.
• Ammonia scavenging therapyif >150 (cvvh)
• cluster nursing care to reduce frequent stimulation.
