User:Samir/A

Acute liver failure

Acute liver failure != chronic liver failure

Definition

AASLD definition = 1. coagulopathy 2. encephalopathy 3. <=26 weeks (not 8, not 6)

  • Causes: Viral hepatitis (A rare B C rare D E (in pregnancy) EBV CMV Herpes VZV hemophagocytic syndrome). Alcohol (MDF>32 -> steroids, PTX). Acetaminophen. Amanita phylloides. Toxins. Autoimmune. Wilson. Ischemia. Rarely tumour/Budd-Chiari
  • Presentation: Encephalopathy (ABC, intubate if PSE III, IV), jaundice, fever, hypotension, hypoglycemia, coma
  • The only active management -> EtOH, autoimmune, herpes viruses, Amanita (silibylin!)
  • Else supportive!
  • Testing: CBC, lytes, Cr!, glc!, PT, INR, alb, LFTs, ->
  • Virus (A IgM, B sAg sAb eAg cIgM, C Ab +- RNA, D Ab (?) delta factor test, E Ab.)
  • EtOH/Acetaminophen levels
  • ANA SMA SPEP/QI
  • Ceruloplasmin. 24 h U Cu
  • TOX
  • EBV/CMV if indicated
  • US + doppler
  • CT
  • Glucoscans
  • ICU admit
  • +- Bx
  • King's College Criteria!!
    • Acetaminophen -> pH<7.3 OR all of INR>6.5, Cr>300, PSE III +
    • Non-acetaminophen -> INR > 6.5 OR 3 of INR>3.5, Bili > 300, Jaundice to coma > 7 d, non-viral cause, age <10 or >40
  • Mx:
  • Neurovitals -> follow for ICP
  • Lactulose oral/NG 30 q2 or enema 300+700
  • NAC! You are not giving enough NAC!!! 150 x 30 min, 50 x 4 h, 100 x 16 To all until *Acetaminophen level obtained
  • Glucoscans +- glucose
  • Limit fluids <500 cc/d
  • Check CAMPi
  • Mannitol/Hyperventilation
  • No hepatotoxins/nephrotoxins/sedatives
  • Consider Abx
  • Tx WU -> Consults: ICU/Tx/Toxicology
  • Survey for infection/sz
  • Nutrition
  • Pressors
  • Transplant
  • Wilson's -> support, DPA (nephrotoxicity, rash, SJ, membranous, PPT neurol), Trientine (PPT neurol), TMP, Zn 50 q 4. Low Cu diet (shellfish, peanuts, mmm chocolate), PLEX and MARS??

HRS

  • 5 Major: >133 (1.5)/<40, Hepatic disease, No nephrotoxins/sepsis/obstruction, No proteinuria, No response to 1.5L
  • 5 Minor: No hematuria, low Uo<500/d, U Na < 10, U Osm > S Osm, S Na < 130
  • Mx: admit, NS, U lytes/osm, S osm/lytes/Cr, Abd US, CAMPi, GLC, LFTs/INR/Bili/Alb
  • Midodrine 2.5 q8h -> 7.5 q 8h titrate to HR 90
  • Octreotide 50/h
  • Albumin 300 cc/d (SBP dose = 1.5 g/kg day 1, 1 g/kg day 3)
  • Terlipressin (for article)
  • PTX
  • NAC
  • MARS
  • Transplant

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