Case of the Month #26 - liver failure

Published 10/02/2022

What is the management of a patient with acute liver failure due to paracetamol overdose?

  • ABCDE approach
  • Prompt intubation and ventilation for low GCS to prevent aspiration and facilitate management of brain oedema
  • CT head should be considered to rule out any other potential causes of GCS deterioration
  • Measures to prevent and decrease cerebral edema:
  • PaO2 >10 kPa; PaCO2 between 4.5 to 5.5 kPa
  • Avoid measures that could increase intracranial pressure such as ET tube ties (instead use tapes to secure the ET tube)
  • Deep sedation to avoid cough and strain, and decrease the metabolic demands of the brain
  • Aiming for serum Na>145 mmol/L
  • Avoid hyperthermia
  • Hypertonic solutions such as mannitol if there are signs of brain herniation or dilated unreactive pupils
  • Cardiovascular support: fluid resuscitation with albumin and crystalloids; vasopressors may be required
  • Supportive care for metabolic acidosis: haemofiltration
  • Do not to correct coagulopathy unless actively bleeding (because the coagulation profile is used when in the assessment of potential for liver transplantation)
  • Correct electrolytes: hypokalemia, hypophosphatemia, hyponatremia
  • Dextrose infusion to treat hypoglycemia
  • Sepsis: broad spectrum antibiotics and antifungals
  • Liver transplantation may be required