Acute liver failure is defined as new and rapidly evolving hepatic dysfunction associated with neurologic dysfunction and coagulopathy (INR >1.5). Most common cause of death in these patients are multiorgan failure and sepsis. Drug-induced liver injuy most common cause in US, with viral hepatitis most common cause worldwide.
Management of complications associated with acute liver failure
Hepatic encephlopathy: Administer lactulose orally or via enema if risk of aspiration. Goal is to slow progression to severe encephalopathy and minimize development of cerebral edema.
Coagulopathy: Reverse if significant bleeding or if patient needs to have invasive procedure. FFP and 4-factor PCC not indicated in absence of bleeding. Additionally these patients may be vitamin-K deficient for which vitamin K can be given.
Consider empiric antibiotics due to increased susceptibility to infection.
Renal dysfunction: correct hypovolemia with fluid resuscitation. May require RRT, continuous preferred for hemodynamic stability.
If persistent hypotension despite adequate volume resuscitation and pressors, IV hydrocortisone indicated as adrenal insufficiency is common in these patients.
Early consultation with liver transplant center. King's College Criteria and MELD score are most commonly used prognostic tools.
References
Montrief T, Koyfman A, Long B. Acute liver failure: A review for emergency physicians. Am J Emerg Med. 2019 Feb;37(2):329-337. doi: 10.1016/j.ajem.2018.10.032. Epub 2018 Oct 22. PMID: 30414744.
