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


RESULTS
Intracranial pressure monitoring is recommended in patients with advanced hepatic encephalopathy who are awaiting orthotopic liver transplantation. At an intracranial pressure of > or =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.
Stravitz
R Todd
RT
Section of Hepatology, Virginia Commonwealth University, Richmond, USA. rstravit@hsc.vcu.edu
Kramer
Andreas H
AH
Davern
Timothy
T
Shaikh
A Obaid S
AO
Caldwell
Stephen H
SH
Mehta
Ravindra L
RL
Blei
Andres T
AT
Fontana
Robert J
RJ
McGuire
Brendan M
BM
Rossaro
Lorenzo
L
Smith
Alastair D
AD
Lee
William M
WM
D001929:Brain Edema / Q000209:etiology / Q000628:therapy; D003422:Critical Care; D006801:Humans; D019586:Intracranial Hypertension / Q000209:etiology / Q000628:therapy; D017114:Liver Failure, Acute / Q000150:complications / Q000628:therapy*