Acute Liver Failure

Question 1

In patient w/ ALF and grade 2 or higher encephalopathy, we suggest early CRRT for management of hyperammonemia even in the absence of conventional RRT indications.

Answer 1

conditional, low evidence

Question 2

In patients w/ ALF, in the absence of active bleeding or impending high-risk procedure, we recommend against routine correction of coagulopathy.

Answer 2

conditional, very low evidence

Question 3

In patient w/ ALF, we recommend against the routine use of prophylactic antimicrobial agents, given no improvement in either rate of bloodstream infection or 21-day mortality.

Answer 3

conditional, low evidence

Question 4

In patients w/ ALF, we recommend norepinephrine as the first-line vasopressor for hypotension refractory to fluid resuscitation.

Answer 4

strong, moderate evidence

Question 5

In patients w/ ALF w/ hypotension not responsive to norepinephrine, we suggest adding vasopressin as a secondary agent.

Answer 5

conditional, low

Question 6

In patients w/ suspected APAP toxicity, we recommend early administration of N-acetylcysteine.

Answer 6

strong, low evidence

Question 7

In patients w/ non-APAP ALF, we suggest the initiation of intravenous NAC.

Answer 7

strong, moderate evidence

Question 8

In patients w/ ALF due to reactivation of HBV, we recommend starting antiviral therapy.

Answer 8

strong, low evidence

Question 9

In patients w/ ALF due to mushroom poising, we recommend initiation of IV silibinin as soon as possible. IV penicillin G may be used if IV silibinin is unavailable.

Answer 9

conditional, very low evidence

Question 10

In patients w/ ALF, we recommend using either the KCC criteria or MELD score for prognostication. Patients meeting the KCC criteria or presenting w/ MELD > 25 are at high risk of poor outcomes.

Answer 10

conditional, low evidence