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Intensive care of patients with acute liver failure: Recommendations of the U.S. Acute Liver Failure Study Group

Stravitz, R Todd MD; Kramer, Andreas H. MD, MSc; Davern, Timothy MD; Shaikh, A Obaid S. MD; Caldwell, Stephen H. MD; Mehta, Ravindra L. MD; Blei, Andres T. MD; Fontana, Robert J. MD; McGuire, Brendan M. MD; Rossaro, Lorenzo MD; Smith, Alastair D. MD; Lee, William M. MD

doi: 10.1097/01.CCM.0000287592.94554.5F
Continuing Medical Education Article

Objective: To provide a uniform platform from which to study acute liver failure, the U.S. Acute Liver Failure Study Group has sought to standardize the management of patients with acute liver failure within participating centers.

Methods: In areas where consensus could not be reached because of divergent practices and a paucity of studies in acute liver failure patients, additional information was gleaned from the intensive care literature and literature on the management of intracranial hypertension in non-acute liver failure patients. Experts in diverse fields were included in the development of a standard study-wide management protocol.

Measurements and Main Results: Intracranial pressure monitoring is recommended in patients with advanced hepatic encephalopathy who are awaiting orthotopic liver transplantation. At an intracranial pressure of ≥25 mm Hg, osmotic therapy should be instituted with intravenous mannitol boluses. Patients with acute liver failure should be maintained in a mildly hyperosmotic state to minimize cerebral edema. Accordingly, serum sodium should be maintained at least within high normal limits, but hypertonic saline administered to 145–155 mmol/L may be considered in patients with intracranial hypertension refractory to mannitol. Data are insufficient to recommend further therapy in patients who fail osmotherapy, although the induction of moderate hypothermia appears to be promising as a bridge to orthotopic liver transplantation. Empirical broad-spectrum antibiotics should be administered to any patient with acute liver failure who develops signs of the systemic inflammatory response syndrome, or unexplained progression to higher grades of encephalopathy. Other recommendations encompassing specific hematologic, renal, pulmonary, and endocrine complications of acute liver failure patients are provided, including their management during and after orthotopic liver transplantation.

Conclusions: The present consensus details the intensive care management of patients with acute liver failure. Such guidelines may be useful not only for the management of individual patients with acute liver failure, but also to improve the uniformity of practices across academic centers for the purpose of collaborative studies.

Associate Professor of Medicine, Section of Hepatology, Virginia Commonwealth University, Richmond, VA (RTS); Assistant Clinical Professor, Departments of Critical Care Medicine and Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, Canada (AHK); Associate Professor of Medicine, Department of Medicine/Gastroenterology, UCSF Liver Transplant Program, University of California at San Francisco, San Francisco, CA (TD); Associate Professor of Medicine, Center for Liver Diseases, University of Pittsburgh, Pittsburgh, PA (AOSS); Director of Hepatology, University of Virginia, Charlottesville, VA (SHC); Professor of Clinical Medicine, Associate Chair, Clinical Affairs, Department of Medicine, University of California at San Diego, San Diego, CA (RLM); Professor of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (ATB); Associate Professor of Medicine, Medical Director, Liver Transplantation, Department of Medicine, University of Michigan Medical Center, Ann Arbor, MI (RJF); Associate Professor of Medicine, University of Alabama, Birmingham, AL (BMM); Chief, Gastroenterology and Hepatology, Professor of Clinical Medicine, University of California at Davis, Sacramento, CA (LR); Assistant Professor of Medicine, Division of Gastroenterology, Duke University Medical Center, Durham, NC (ADS); Professor of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX (WML).

Supported, in part, by National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases grant DK058369 (ALFSG, with WML as principal investigator).

Current address for Dr. Kramer: Departments of Critical Care Medicine and Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada.

For information regarding this article, E-mail: rstravit@hsc.vcu.edu

© 2007 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins