14 Questions
What is the characteristic feature of acute liver failure (ALF)?
Abnormal liver tests
According to the 2023 Acute Liver Failure Guidelines, what is the recommendation for ALF patients with grade 3 encephalopathy?
Intubation for airway protection
What is the recommendation regarding the use of lactulose or rifaximin for the treatment of encephalopathy in ALF patients?
No conclusive evidence to recommend for or against their use
In ALF patients with grade 2 or higher hepatic encephalopathy, what is the suggested management for hyperammonemia?
Early continuous renal replacement therapy
What is the recommendation regarding the correction of INR in ALF patients in the absence of active bleeding or impending high-risk procedure?
Recommend against routine correction of INR
What may provide a more accurate assessment of coagulopathy in patients with ALF compared to INR?
Viscoelastic tests
What should be the course of action for ALF patients with grade 2 or higher encephalopathy?
Monitoring in an ICU
What is the recommended first-line vasopressor for hypotension refractory to fluid resuscitation in patients with ALF?
Norepinephrine
What is the suggested secondary agent for hypotension not responsive to norepinephrine in patients with ALF?
Vasopressin
What is the recommended treatment initiation for patients with ALF due to mushroom poisoning?
IV silibinin
What is the recommended initial treatment for patients with non-APAP ALF?
IV NAC
What is the recommended action for patients with ALF and Hepatic Encephalopathy Grade 1?
Initiate IV NAC
Why is early assessment for infection considered prudent in patients with ALF?
Due to frequent absence of clinical signs of infection
Why is the routine use of prophylactic antibiotics not recommended in patients with ALF?
No improvement in rate of bloodstream infection or 21-day mortality
Study Notes
Acute Liver Failure (ALF)
- Characteristic feature: No specific definition, but a combination of clinical and biochemical features
Management of ALF Patients
- Patients with grade 3 encephalopathy: Intensive care unit (ICU) admission recommended
- Treatment of encephalopathy: No recommendation for lactulose or rifaximin use
- Patients with grade 2 or higher hepatic encephalopathy: Hyperammonemia management involves reduction of ammonia production and enhancement of ammonia removal
Coagulopathy Management
- INR correction: Not recommended in the absence of active bleeding or impending high-risk procedure
- More accurate assessment of coagulopathy: Viscoelastic tests (e.g., thromboelastography) compared to INR
Treatment of ALF Patients
- Patients with grade 2 or higher encephalopathy: Consideration for ICU admission and urgent evaluation for liver transplantation
- First-line vasopressor for hypotension refractory to fluid resuscitation: Norepinephrine
- Secondary agent for hypotension not responsive to norepinephrine: Vasopressin
- Patients with ALF due to mushroom poisoning: Silibinin treatment initiation
- Patients with non-APAP ALF: Initial treatment with N-acetylcysteine (NAC) not recommended
- Patients with ALF and Hepatic Encephalopathy Grade 1: Close monitoring and supportive care
Infection Management
- Early assessment for infection: Prudent due to high risk of bacterial infections
- Prophylactic antibiotics: Not recommended for routine use in patients with ALF
Test your knowledge of acute liver failure in the emergency department with this quiz. Explore the causes, symptoms, and guidelines for managing this life-threatening condition, including the impact of mushroom experimentation and over-the-counter herbal supplements.
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