User:Samir/A

=Acute liver failure= Acute liver failure != chronic liver failure

Definition
AASLD definition = 1. coagulopathy 2. encephalopathy 3. <=26 weeks (not 8, not 6)


 * Causes: Viral hepatitis (A rare B C rare D E (in pregnancy) EBV CMV Herpes VZV hemophagocytic syndrome). Alcohol (MDF>32 -> steroids, PTX).  Acetaminophen.  Amanita phylloides.  Toxins.  Autoimmune.  Wilson.  Ischemia. Rarely tumour/Budd-Chiari


 * Presentation: Encephalopathy (ABC, intubate if PSE III, IV), jaundice, fever, hypotension, hypoglycemia, coma


 * The only active management -> EtOH, autoimmune, herpes viruses, Amanita (silibylin!)


 * Else supportive!


 * Testing: CBC, lytes, Cr!, glc!, PT, INR, alb, LFTs, ->
 * Virus (A IgM, B sAg sAb eAg cIgM, C Ab +- RNA, D Ab (?) delta factor test, E Ab.)
 * EtOH/Acetaminophen levels
 * ANA SMA SPEP/QI
 * Ceruloplasmin. 24 h U Cu
 * TOX
 * EBV/CMV if indicated
 * US + doppler
 * CT
 * Glucoscans
 * ICU admit
 * +- Bx


 * King's College Criteria!!
 * Acetaminophen -> pH<7.3 OR all of INR>6.5, Cr>300, PSE III +
 * Non-acetaminophen -> INR > 6.5 OR 3 of INR>3.5, Bili > 300, Jaundice to coma > 7 d, non-viral cause, age 40


 * Mx:
 * Neurovitals -> follow for ICP
 * Lactulose oral/NG 30 q2 or enema 300+700
 * NAC! You are not giving enough NAC!!!  150 x 30 min, 50 x 4 h, 100 x 16  To all until *Acetaminophen level obtained
 * Glucoscans +- glucose
 * Limit fluids <500 cc/d
 * Check CAMPi
 * Mannitol/Hyperventilation
 * No hepatotoxins/nephrotoxins/sedatives
 * Consider Abx
 * Tx WU -> Consults: ICU/Tx/Toxicology
 * Survey for infection/sz
 * Nutrition
 * Pressors
 * Transplant


 * Wilson's -> support, DPA (nephrotoxicity, rash, SJ, membranous, PPT neurol), Trientine (PPT neurol), TMP, Zn 50 q 4. Low Cu diet (shellfish, peanuts, mmm chocolate), PLEX and MARS??

=HRS=
 * 5 Major: >133 (1.5)/<40, Hepatic disease, No nephrotoxins/sepsis/obstruction, No proteinuria, No response to 1.5L
 * 5 Minor: No hematuria, low Uo<500/d, U Na < 10, U Osm > S Osm, S Na < 130
 * Mx: admit, NS, U lytes/osm, S osm/lytes/Cr, Abd US, CAMPi, GLC, LFTs/INR/Bili/Alb
 * Midodrine 2.5 q8h -> 7.5 q 8h titrate to HR 90
 * Octreotide 50/h
 * Albumin 300 cc/d (SBP dose = 1.5 g/kg day 1, 1 g/kg day 3)
 * Terlipressin (for article)
 * PTX
 * NAC
 * MARS
 * Transplant