Acute liver failure (ALF) is a condition of acute hepatic emergency where rapid deterioration of hepatocyte function leads to hepatic encephalopathy, coagulopathy, cerebral edema (CE), infection and multi-organ dysfunction syndrome resulting in a high mortality rate. Urgent liver transplantation is the standard of care for most of these patients in Western countries. However, in India, access to liver transplantation is severely limited and, hence, the management is largely based on intensive medical care. With earlier recognition of disease, better understanding of pathophysiology and improved intensive care, ALF patients have shown a significant improvement in spontaneous survival. An evidence base for practice for supportive care is still lacking; however, intensive organ support as well as control of infection and CE are likely to be key to the successful outcome in this acute and potentially reversible condition without any sequel. A structured approach to decision making about intensive care is important in each case. Unlike in Western countries where acetamenophen is the most common cause of ALF, the role of a specific agent, such as N-acetylcysteine, is limited in India. Ammonia-lowering therapy is still in an evolving phase. The current review highlights the important medical management issues in patients with ALF in general as well as the management of major complications associated with ALF. We performed a MEDLINE search using combinations of the key words such as acute liver failure, intensive treatment of acute liver failure and fulminant hepatic failure. We reviewed the relevant publications with regard to intensive care of patients with ALF.
Acute liver failure: redefining the syndromes. Lancet 1993;342:273-5.
Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. Ann Intern Med 2002;137:947-54.
Outcomes following liver transplantation for seronegative acute liver failure: experience during a 12-year period with more than 100 patients. Liver Transpl 2005;11:27-34.
Acute liver failure. Gut 1991;Suppl:S86-91.
Effect of lidocaine on ICP response to endotracheal suctioning. Anesthesiology 1986;64:651-3.
Advances in critical care hepatology. Am J Respir Crit Care Med 2003;168:1421-6.
Effects of head posture on cerebral hemodynamics: Its influences on intracranial pressure, cerebral perfusion pressure, and cerebral oxygenation. Neurosurgery 2004;54:593-7; discussion 598.
Cerebral perfusion pressure, intracranial pressure, and head elevation. J Neurosurg 1986;65:636-41.
Factors associated with severe intracranial hypertension in candidates for emergency liver transplantation. Transplantation 1993;55:1071-4.
Efficacy of oral N-acetylcysteine in the treatment of acetaminophen overdose. Analysis of the national multicenter study (1976 to 1985). N Engl J Med 1988;319:1557-62.
Improved outcome of paracetamol-induced fulminant hepatic failure by late administration of acetylcysteine. Lancet 1990;335:1572-3.
Intravenous N-acetylcysteine improves transplant-free survival in early stage non-acetaminophen acute liver failure. Gastroenterology 2009;137:856-64.
Antituberculosis therapy-induced acute liver failure: magnitude, profile, prognosis, and predictors of outcome. Hepatology 2010;51:1665-74.
Safety and efficacy of lamivudine in patients with severe acute or fulminant hepatitis B, a multicenter experience. J Viral Hepat 2006;13:256-63.
Usefulness ofcorticosteroids for the treatment of severe and fulminant forms of autoimmune hepatitis. Liver Transpl 2007;13:996-1003.
Acute fatty liver of pregnancy. Crit Care Clin 1991;7:799-808.
N Engl J Med 2000;342:1301-8.
Changes in hepatic flow induced by continuous positive pressure ventilation in critically ill patients. Crit Care Med 1982;10:703-5.
Cerebral blood flow and metabolism in fulminant liver failure. Hepatology 1994;19:1407-13.
Transcranial doppler sonography and internal jugular bulb saturation during hyperventilation in patients with fulminant hepatic failure. Liver Transpl 2001;7:352-8.
Controlled hyperventilation in the prevention of cerebral oedema in fulminant hepatic failure. J Hepatol 1986;2:43-51.
Hyperglycemia is associated with intracranial hypertension in patients with acute liver failure. Liver Transpl 2001;7:C21.
Energy expenditure in acetaminophen-induced fulminant hepatic failure. Crit Care Med 2000;28:649-54.
Malnutrition and immuno-incompetence in patients with liver disease. Lancet 1980;2:615-7.
Nutritional therapies in liver disease. Semin Liver Dis 1991;11:278-91
Clinical practice of nutrition in acute liver failure-a European survey. Clin Nutr 2004;23:975-82.
Treatment of brain edema in acute liver failure. Curr Treat Options Neurol 2010;12:129-41.
Early changes in intracranial pressure during haemofiltration treatment in patients with grade 4 hepatic encephalopathy and acute oliguric renal failure. Nephrol Dial Transplant 1990;5:192-8.
Continuous renal replacement therapy in the critically ill patient. Kidney Int 2005;67:781-95.
Improved cardiovascular stability during continuous modes of renal replacement therapy in critically ill patients with acute hepatic and renal failure. Crit Care Med 1993;21:328-38.
Hemodynamic effects of cardiac cyclespecific increases in intrathoracic pressure. J Appl Physiol 1986;60:604-12.
Effect of synchronous increase in intrathoracic pressure on cardiac performance during acute endotoxemia. J Appl Physiol 1990;69:1502-8.
Direct comparison of cerebrovascular effects of norepinephrine and dopamine in head-injured patients. Crit Care Med 2004;32:1049-54.
Effects of dopamine, norepinephrine, and epinephrine on the splanchnic circulation in septic shock: which is best? Crit Care Med 2003;31:1659-67.
Worsening of cerebral hyperemia by the administration of terlipressin in acute liver failure with severe encephalopathy. Hepatology 2004;39:471-5.
Comparison of terlipressin and noradrenalin on cerebral perfusion, intracranial pressure, and cerebral extracellular concentrations of lactate and pyruvate in patients with acute liver failure in need of inotropic support. J Hepatol 2007;47:381-6.
Bacterial and fungal infection in acute liver failure. Semin Liver Dis 1996;16:389-402.
Prospective controlled trial of selective parenteral and enteral antimicrobial regimen in fulminant liver failure. Hepatology 1993;17:196-201.
Infection and the progression of hepatic encephalopathy in acute liver failure. Gastroenterology 2003;125:755-64.
The systemic inflammatory response syndrome in acute liver failure. Hepatology 2000;32:734-9.
Acute hepatic failure in India: a perspective from the East. J Gastroenterol Hepatol 2000;15:473-9.
Cerebral edema: A major complication of massive hepatic necrosis. Gastroenterology 1971;61:877-84.
Intracranial pressure monitoring and liver transplantation for fulminant hepatic failure. Hepatology 1992;16:1-7.
Acute liver failure: results of a 5-year clinical protocol. Liver Transpl Surg 1995;1:210-9.
The safety and value of extradural intracranial pressure monitors in fulminant hepatic failure. J Hepatol 1993;18:205-9.
Complications and use of intracranial pressure monitoring in patients with acute liver failure and severe encephalopathy. Liver Transpl 2005;11:1581-9.
Complications of intracranial pressure monitoring in fulminant hepatic failure. Lancet 1993;341:157-8.
Controlled trial of dexamethasone and mannitol for the cerebral oedema of fulminant hepatic failure. Gut 1982;23:625-9.
Mannitol dose requirements in brain-injured patients. J Neurosurg 1978;48:169-72.
Clinical monitoring of intracranial pressure in fulminant hepatic failure. Gut 1980;21:866-9.
Randomized, controlled trial on the effect of a 20% mannitol solution and a 7.5% saline/6% dextran solution on increased intracranial pressure after brain injury. Crit Care Med 2005;33:196-202; discussion 257-8.
Effects of 23.4% sodium chloride solution in reducing intracranial pressure in patients with traumatic brain injury: A preliminary study. Neurosurgery 2005;57:727-36; discussion 727-36.
The effect of hypertonic sodium chloride on intracranial pressure in patients with acute liver failure. Hepatology 2004;39:464-70.
Moderate hypothermia in patients with acute liver failure and uncontrolled intracranial hypertension. Gastroenterology 2004;127:1338-46.
Application of therapeutic hypothermia in the intensive care unit: opportunities and pitfalls of a promising treatment modality: part 2. Practical aspects and side effects. Intensive Care Med 2004;30:757-69.
Thiopental infusion in the treatment of intracranial hypertension complicating fulminant hepatic failure. Hepatology 1989;10:306-10.
The effect of indomethacin on intracranial pressure, cerebral perfusion, and extracellular lactate and glutamate concentrations in patients with fulminant hepatic failure. J Cereb Blood Flow Metab 2004;24:798-804.
Pathophysiology of brain edema in fulminant hepatic failure, revisited. Metab Brain Dis 2001;16:85-94.