Liver Failure
12/5/11
AGENTS
-
paracetamol
iron
idiosyncratic
illicit
alcohol
CLINICAL FEATURES
-
asymptomatic
nausea and vomiting
RUQ pain
jaundice
coagulopathy
hypoglycaemia
ENCEPHALOPATHY
- sleep disturbance
- asterixis
- hyper-reflexic
- can be hemiplegic
- precipitating factor: GIH, infection, hypokalaemia, sedatives, increased protein intake,
progressive hepatic dysfunction, renal failure
- types: A = acute liver failure, B = presence of portocaval shunting, C = in context of
cirrhosis
- grade I -> IV: mildly drowsible but rousable and coherent -> responding to
pain/unconscious
INVESTIGATIONS
- level as indicated
-> paracetamol: Rumack-Matthews nomogram @ 4 hours or within 8 hours of OD
-> iron level: > 90 micromoles/L (children), > 145 micromoles/L (adults) within 4
hours of ingestion.
- LFT’s
- coagulation
- glucose
- renal function
SPECIFIC MANAGEMENT AND TRIGGERS FOR INTERVENTION
- early discussion with liver transplant unit
- attempt not to reverse coagulopathy until discussion unless actively bleeding
- avoid renal and hepatotoxic agents
Jeremy Fernando (2011)
Paracetamol
- decrease absorption: activated charcoal if presented within 4 hours (controversial as if NAC
given then this is a benign OD)
- vitamin K IV
- N-acetyl cystine in D5W (based on 4 hour level or empirically if > 8 hours since OD):
-> 150mg/kg LD
-> 50mg/kg over 4 hours
-> 100mg/kg over 16 hours
Iron
- gastric lavage with large bore tube (2gm of desferrioxamine in 1L warm water -> leave 10g
in 50mL in stomach to chelate any remaining iron)
- IV or IM desferrioxamine (1gm loading dose -> 500mg Q4 hrly depending on severity –
maximum = 6g in 24 hrs)
- desferrioxamine -> binds Fe2+ to form water soluble ferrioxamine that is renally excreted
- can use HCO3- (controversial)
- whole bowel irrigation with polyethylene glycol
- gastric lavage
- laparotomy or endoscopic tablet removal (if tablets seen on plain XR)
- exchange transfusion with plasmapheresis
- dialysis - limited efficacy
Jeremy Fernando (2011)