Acute Liver Failure Dr Steve Gill Consultant in ICM and Anaesthesia Nottingham University Hospitals Follow me on twitter @ICMDoc
Objectives Understand the definitions and common causes of
acute liver failure
Discuss the clinical features and management options
Describe the indications for referral to a transplant centre
Consider the specific considerations for post-resection liver failure
Definitions
Varying definitions
Typically based on time from symptoms to encephalopathy
Slower onset may be confused for chronic liver disease
Causes
Viruses
Drugs
Autoimmune
Others
Clinical features
Management - general Airway/Breathing - for low GCS
Circulation - typically high CO with low SVR
ICP management
Maintain glucose level
Correct only coagulopathy if bleeding
Antibiotics
Nutrition
CVVH
Management - specific
n-acetylcystiene
Lactulose
Steroids
Transplantation
When to refer Paracetamol
pH<7.3
Or all three of …
INR>6.5
Creatinine >300
Grade III or IV encephalopathy
Non-Paracetamol
INR >6.5
Or 3 of …
Age <11 or >40
Bilirubin >300
Jaundice to coma >7/7
INR >3.5
Drug toxicity
Post-Liver Resection Failure Defined as “a postoperative acquired deterioration …
increased INR and bilirubin on or after day 5”
Grade A - abnormal lab parameters but no change in management
Grade B - change in normal post op management required but without invasive treatment
Grade C - requiring invasive treatment
Risk factors for post-resection liver failure
Size of resection
Preoperative liver disease
Ischaemia/reperfusion injury
Prevention
Patient selection and surgical strategy
Anaesthetic agent
Minimise blood loss
Insulin therapy
Ischaemic preconditioning
Management Optimise & support ABCDE
Rule out vascular compromise
Treat infection
N-acetylcystine
Nutrition & laxatives
Reduce portal venous flow
Rescue hepatectomy and transplantation
Any questions??
Summary Acute liver failure carries high mortality especially in the
developing world where viral infection is the commonest cause
Treatment is mostly supportive
Post-resection liver failure can be risk assessed and steps take to prevent and treat it throughout the preoperative course
Transplantation is effective in a number of situations but limited by donor availability
I will post links to this talk and relevant papers via twitter later today (hopefully) @ICMDoc