Intensive Care Management of Severe Acute Liver Failure

Severe acute liver failure is defined as the development of overt liver failure with encephalopathy over eight weeks or less in previously healthy individuals. In hyperacute liver failure, deterioration occurs in less than 14 days. Whilst it is a relatively uncommon reason for admission to the intensive care unit (ICU), acute liver failure is important because it often occurs in previously well young adults and carries a high mortality. Management of these patients presents considerable challenges within the ICU due to the extreme nature of the associated pathophysiological processes, which affect multiple systems. Integrated management strategies have been poorly studied and treatment is often center-specific [1]. Clinical manifestations include a reduced conscious state, jaundice with abnormal liver function tests (especially elevations in amino acid transferase levels more than 25 times the upper limit of normal) and coagulopathy. Further deterioration can involve marked cerebral edema, hypoglycemia and severe shock with lactic acidosis and multiple organ failure. The use of clinical management guidelines may assist in the treatment of these patients by providing an evidence-based framework for care by staff at the bedside, which ensures that all important priorities are adequately addressed. It is possible that a coordinated combination of specific and general therapies may reduce mortality and the need for liver transplantation. Consideration for transfer to a unit with expertise in liver transplantation may be appropriate in order for this option to be available as a life-saving treatment should supportive care fail to arrest deterioration.