Internal Medicine

0521779407-07 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:10

594 Fulminant Hepatic Failure

➣hypergammaglobulinemia

➣positive ANA

differential diagnosis

■Acute liver failure superimposed on previously unrecognized

chronic liver disease, e.g. exacerbation of chronic hepatitis B

management

What to Do First

■Confirm diagnosis

■Assess severity of disease and need for ICU monitoring and care

■Assess possible liver transplant

General Measures

■Full hemodynamic monitoring (arterial line, pulmonary artery

catheter)

■Endotracheal intubation and intracranial pressure monitoring for

stage 3 encephalopathy

■Parenteral glucose (D10–20) to prevent hypoglycemia

■Correct electrolyte and acid base disorders

■Parenteral H2 blocker infusion to minimize chance of GI bleeding

■Treat elevated intracranial pressure with mannitol

■Treat fever with broad spectrum antibiotics after cultures, and con-

sider antifungal therapy

specific therapy

■Acetaminophen poisoning

➣gastric lavage with large bore tube to remove any pills still present

➣N-acetylcysteine per nasogastric tube

■Cerebral edema:

➣treat to maintain the cerebral perfusion pressure (MAP minus

ICP) gradient >50 mm Hg

➣general measures

decrease tactile stimulation

raise head of bed 20–30 degrees

avoid hypotension, hypoxia, and hypercarbia

➣specific measures

mannitol q hr until effect; ineffective in patient with renal fail-

ure unless coupled with CVVH or ultrafiltration, or in patients

with osmolarity >310 mosm

hyperventilation (consider in stage 4 encephalopathy). Liver

transplantation