management of acute hepatic failure

Last reviewed 02/2023

Management of this condition depends considerably on the severity of the symptoms. The principal indicator will be the grade of encephalopathy experienced by the patient.

Principles of management are:

• intensive care situation nursing - transfer to specialist centre to ensure optimal treatment
• monitor hourly the blood glucose, urine output, vital signs
• monitor twice daily the potassium, full blood count, creatinine, albumin, coagulation
• do not administer IV saline - there is a secondary hyperaldosteronism in hepatic failure which causes retention of sodium

Cerebral oedema and sepsis are the commonest causes of death, and profound hypotension and multiorgan failiure frequently occurs. Management of specific problems is dealt with in the relevant area. However:

• hypoglycaemia and hypokalaemia are managed with 10% dextrose at 100 ml per hour with KCl 40mmol per litre; 20 to 50% dextrose may be needed if the hypoglycaemia is severe. Care must be taken not to fluid overload the patient
• infection prophylaxis is important, with meticulous care of catheters. Blood, urine and catheter cultures should be taken before starting antibiotics, and antibiotics may be given prophylactically since patients may be very ill but without common signs of sepsis
• ranitidine helps to keep the gastric pH above 5
• sedatives, protein feeds and drugs with hepatic metabolism should be avoided
• N-acetyl cysteine is well established in paracetamol toxicity, and may be useful as a prolonged therapy. Some evidence also suggests that it may have a role in other forms of acute liver failure.