Skip to main content
SpringerLink
Log in

Acute Liver Failure in Intensive Care

  • Chapter
Book cover Practical Issues in Anesthesia and Intensive Care

  • 1150 Accesses

Abstract

Acute liver failure (ALF) is a rare syndrome characterized by sudden and acute hepatic injury which can be attributed to a number of different causes although not all of them are always clearly identifiable [1–13]. A severe compromise of parenchymal function is followed, at different intervals, by the onset of hepatic encephalopathy, serious haemostasis alteration and, in many cases, multiple organ failure. In the 70s the term FHF (fulminant hepatic failure) had been introduced to describe serious hepatic damage, in absence of known pre-existing hepatic disease, with subsequent onset of encephalopathy within 8 weeks. The syndrome was described as “potentially reversible” [1, 2, 12]. The definition proposed by O’Grady in 1993 and still used today recognizes that the onset of encephalopathy and of altered awareness at different degree is fundamental from a prognostic point of view [2, 12]. Elevated transaminase, hyperbilrubinemia, encephalopathy and serious coagulopathy are the main characteristics of ALF [1–7, 10]. All the identifying factors that have been proposed include the onset of encephalopathy in the course of ALF, the lack of pre-existing hepatic disease and the high incidence of spontaneous mortality (>85%). This pathology presents itself in a variety of ways and it may be a combination of different aetiologies, each producing a very different outcome. ALF is identifiable by a progressive bilirubin increase [1–7] within a time span of 7 days to 26 weeks after acute liver damage. Depending on the interval between the onset of jaundice and the clinical signs of encephalopathy, the syndrome is classified as hyper-acute (jaundice-encephalopathy interval: <7 days); acute (jaundice-encephalopathy interval: 8–28 days); sub-acute (jaundice-encephalopathy interval: 28 days–26 weeks). Bernal et al. [1] agree with this classification in the most recent review published on the subject.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 39.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 49.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Bibliografia

  1. Bernal W, Auzinger G, Dhawan A, Wendon J (2010) Acute liver failure. Lancet 376:190–201

    Article  PubMed  Google Scholar 

  2. Grady JC, Schalm SW, Williams R (1993) Acute liver failure: redifining the syndrome. Lancet 342: 273–275

    Article  Google Scholar 

  3. Lee WM (2003) Acute liver failure in USA. Sem Liver Dis 23: 217–226

    Article  CAS  Google Scholar 

  4. Trotter JF (2009) Practical management of acute liver failure in the intensive care unit. Curr Op Crit Care 15:163–167

    Article  Google Scholar 

  5. Stravitz RT (2008) Critical management decisions in patirnts with acute liver failure. Chest 134;1092–1102

    Article  PubMed  Google Scholar 

  6. Auzinger G, Wedon J (2008) Intensive care management of acute hepatic failure. Curr Op Crit Care 14:179–188

    Article  Google Scholar 

  7. Jalan R (2005) Acute liver failure: current management and future perspects. J Hepatol 42: S115–S123

    Article  PubMed  Google Scholar 

  8. Ichai P, Samuel D (2008) Etiology and prognosis of fulminant hepatitis in adults. Liver Transplantation 14:S67–S79

    Article  PubMed  Google Scholar 

  9. Bernal W, Wendon J (2004) Liver transplantation in adults with acute liver failure. J Hepatol 40: 192–197

    Article  PubMed  Google Scholar 

  10. Stravitz RT, Kramer AH, Davern T et al (2007) Intensive care of patients with acute liver failure: recommendations of the US Acute Liver Failure Study Group. Crit Care Med 35:2498–2508

    Article  PubMed  Google Scholar 

  11. Ostapowicz G, Fontana RJ, Schiødt FV et al (2002) Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. Ann Intern Med 137:947–954

    PubMed  Google Scholar 

  12. O’Grady JG (2005) Acute liver failure. Postgrad Med J 81:148–154

    Article  PubMed  Google Scholar 

  13. Khashab M, Tector J, Kwo PJ (2007) Epidemiology of acute liver failure. Current Gastroenterology Reports 9:66–73

    Article  PubMed  Google Scholar 

  14. De Carlis L, De Gasperi A et al (2001) Liver transplantation for ecstasy induced fulminant hepatic failure. Transpl Proc 33:2743–2744

    Article  Google Scholar 

  15. Munoz SJ, Reddy RK, Lee W (2008) The coagulopathy of acute liver failure and implications for intracranial pressure monitoring. Neurocrit Care 9:103–107

    Article  PubMed  Google Scholar 

  16. Lisman T, Leebeek F (2007) Hemostatic alterations in liver disease: a review on pathophysiology, clinical consequences, and treatment. Dig Surg 24:250–258

    Article  PubMed  Google Scholar 

  17. De Gasperi A, Corti A, Mazza E et al (2009) Acute liver failure: managing coagulopathy and the bleeding diathesis. Transpl Proc 41:1256–1259

    Article  Google Scholar 

  18. O’Grady JC, Alexander GJ, Hayllar KM, Williams R (1989) Early predictors of prognosis in fulminant hepartic failure. Gastroenterology 97:439–445

    PubMed  Google Scholar 

  19. Bernal W, Donaldson N, Wyncoll D, Wendon J (2002) Blood lactate as an early predictor of outcome in paracetamol-induced acute liver failure: a cohort study. Lancet 358:558–563

    Article  Google Scholar 

  20. Riordan SM, William R (2003) Mechanisms of hepatic injury, multiorgan failure and prognostic criteria in ALF. Sem Liver Dis 23:204–215

    Google Scholar 

  21. Schmidt LE, Larsen FS (2006) Prognostic implications of hyperlactatemia, multiple organ failure and systemic inflammatory response syndrome in patients with acetaminophen-induced acute liver failure. Crit Care Med 34:337–343

    Article  PubMed  Google Scholar 

  22. Devlin J, O’Grady J (1999) Indications for referral and assessment in adult liver transplantation: a clinical guideline. Gut 45(Suppl VI):1–22

    Google Scholar 

  23. Elinav E, Ben-Dov I, Hai-Am E et al (2005) The predictive value of admission and follow-up factor V and VII levels in patients with acute hepatitis and coagulopathy. J Hepatol 42: 82–86

    Article  PubMed  CAS  Google Scholar 

  24. Bernuau J, Goudeau A, Poynard T et al (1986) Multivariate analysis of prognostic factors in fulminant hepatitis B. Hepatology 6:648–651

    Article  PubMed  CAS  Google Scholar 

  25. Bernuau J, Samuel D, Durand F et al (1991) Criteria for emergency liver transplantation in patients with acute viral hepatitis and factor V below 50% of normal: A prospective study. Abstr Hepatology 14:49A

    Google Scholar 

  26. Lee WM et al (2009) Intravenous n-acetylcysteine improves transplant-free survival in early stage non-acetaminophen acute liver failure. Gastroenterology 137:856–864

    Article  PubMed  CAS  Google Scholar 

  27. Riordan SM, Williams R (2010) Management of non-acetaminophen-induced ALF. Nat Rev Gastroenterol Hepatol 7: 75–77

    Article  PubMed  CAS  Google Scholar 

  28. Jalan R, Plevris JN, Jalan QR et al (1994) A pilot study of indocyanine green as an early predictor of graft function. Transplantation 58:196–200

    PubMed  CAS  Google Scholar 

  29. Hetz H, Ploechl W, Berlakovich GA et al (2001) Intraoperative indocyanine green kinetics predict postoperative graft function after OLT for chronic hepatic failure. Am J Transplantation 1(Suppl 1):313

    Google Scholar 

  30. Hetz H, Faibyk P, Baker A et al (2002) Non invasive detection of ICG kinetics in OLT. Intensive Care Med 28:S1

    Article  Google Scholar 

  31. Mazza E, Prosperi M, De Gasperi A et al (2008) PDR ICG after liver transplantation: always a reliable tool to predict graft function and outcome? Liver Transplantation 14:476

    Google Scholar 

  32. Frontera JA, Kalb T (2010) Neurological management of fulminant hepatic failure. Neurocrit Care. doi: 10.1007/s12028-010-9470-y

    Google Scholar 

  33. Vaquero J, Chung C, Cahill ME, Blei AT (2003) Pathogenesis of hepatic encephalopathy in acute liver failure. Sem Liver Dis 23: 259–269

    Article  CAS  Google Scholar 

  34. Tofteng F, Hauerberg J, Hansen BA et al (2006) Persistent arterial hyperammonemia increases the concentration of glutamine and alanine in the brain and correlates with intracranial pressure in patients with fulminant hepatic failure. J Cereb Blood Flow Metab 26:21–27

    Article  PubMed  CAS  Google Scholar 

  35. Bhatia V, Singh R, Acharya SK (2006) Predictive value of arterial ammonia for complications and outcome in acute liver failure. Gut 55:98–104

    Article  PubMed  CAS  Google Scholar 

  36. Bernal W, Hall C, Karvellas CJ et al (2007) Arterial ammonia and clinical risk factors for encephalopathy and intracranial hypertension in acute liver failure. Hepatology 46:1844–1852

    Article  PubMed  CAS  Google Scholar 

  37. Jalan R (2003) Intracranial hypertension in ALF: pathophysiological basis of rational management. Sem Liver Dis 23: 271–282

    Article  Google Scholar 

  38. Eefsen M, Dethloff T, Frederiksen HJ (2007) Comparison of terlipressin and noradrenalin on cerebral perfusion, intracranial pressure and extracellular concentrations of lactate and pyruvate in patients with acute liver failure in need of inotropic support. J Hepatol 47:381–386

    Article  PubMed  CAS  Google Scholar 

  39. Pinsky MR, Payen D (2005) Functional hemodynamic monitoring. Crit Care 9: 566–572

    Article  PubMed  Google Scholar 

  40. Parekh NK, Hynan LS, De Lemos J et al (2007) Elevated troponin I levels in acute liver failure: is myocardial injury an integral part of acute liver failure? Hepatology 45:1489–1495

    Article  PubMed  CAS  Google Scholar 

  41. Harry R, Auzinger G, Wendon J (2002) The clinical importance of adrenal insufficiency in acute hepatic dysfunction. Hepatology 36: 395–402

    Article  PubMed  CAS  Google Scholar 

  42. Auzinger G, Sizer E, Bernal W et al (2004) Incidence of lung injury in acute liver failure: diagnostic role of extravascular lung water index. Crit Care 8 (Suppl 1):40

    Article  Google Scholar 

  43. Dellinger R.P, Levy MM, Carlet JM et al (2008) Surviving sepsis campaign: international Guidelines. Intensive Care Med 34:17–60

    Article  PubMed  Google Scholar 

  44. Donahoe M (2006) Basic ventilator management: lung protective strategies. Surg Clin North Am 6:1389–1408

    Article  Google Scholar 

  45. Petrucci N, Iacovelli W (2007) Lung protective ventilation strategy for the acute respiratory distress syndrome. Cochrane Database of Systematic Reviews Issue 3, Art No CD003844

    Google Scholar 

  46. Lichtenstein DA, Mezieres GA (2008) Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 134:117–125

    Article  PubMed  Google Scholar 

  47. Malbrain ML, Cheatham M (2004) Cardiovascular effects and optimal preload markers in intraabdominal hypertension. In: Vincent JL (ed) Yearbook of intensive care and emergency medicine, pp 519–543. Springer, New York

    Google Scholar 

  48. Moore K. Renal failure in ALF (1999) Eur J Gastroenterology 11:967–975

    Article  CAS  Google Scholar 

  49. Hadengue A, Gadano A, Moreno R et al (1998) Beneficial effects of 2 day administration of terlipressin in patients with cirrhosis and hepatorenal syndrome. J Hepatology 29:565–570

    Article  CAS  Google Scholar 

  50. Uriz J, Gines P, Cardenas A et al (2000) Terlipressin plus albumin infusion: an effective and safe therapy of hepatorenal syndrome. J Hepatology 33:43–48

    Article  CAS  Google Scholar 

  51. Duvoux C, Zanditenas D, Hézode C et al (2002) Effects of noradrenalin and albumin in patients with type 1 hepatorenal syndrome: a pilot study. Hepatology 36:374–380

    Article  PubMed  CAS  Google Scholar 

  52. Ronco C, Bellomo R, Homel P et al (2000) Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 356:1441

    Google Scholar 

  53. Mehta RL (2005) Continuous renal replacement therapy in the critically ill patient. Kidney Int 267:781–795

    Article  Google Scholar 

  54. Fiaccadori E, Maggiore U, Rotelli C et al (2002) Continuous haemofiltration in acute renal failure with prostacyclin as the sole anti-haemostatic agent. Intensive Care Med 28:586–593

    Article  PubMed  Google Scholar 

  55. Rolando N, Wade J, Davalos M et al (2000) The systemic inflammatory response syndrome in acute liver failure. Hepatology 232:734–739

    Article  Google Scholar 

  56. Rolando N, Philpott-Howard J, Williams R (1996) Bacterial and fungal infection in acute liver failure. Semin Liver Dis 16:389–402

    Article  PubMed  CAS  Google Scholar 

  57. Vaquero J, Polson J, Chung C et al (2003) Infection and the progression of hepatic encephalopathy in acute liver failure. Gastroenterology 125:755–764

    Article  PubMed  Google Scholar 

  58. Antoniades CG, Berry PA, Davies ET et al (2006) Reduced monocyte HLA-DR expression: a novel biomarker of disease severity and outcome in acetaminophen induced acute liver failure. Hepatology 44:34–43

    Article  PubMed  CAS  Google Scholar 

  59. Rolando N, Gimson A, Wade J et al (1993) Prospective controlled trial of selective parenteral and enteral antimicrobial regimen in fulminant hepatic failure. Hepatology 17:196–201

    Article  PubMed  CAS  Google Scholar 

  60. Pittet D, Monod M, Suter PM et al (1994) Candida colonization and subsequent infections in critically ill surgical patients. Ann Surgery 220:751–758

    Article  CAS  Google Scholar 

  61. De Jonge E, Schultz MJ, Spanjaard L et al (2003) Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial. Lancet 362:1011–1016

    Article  PubMed  Google Scholar 

  62. Koeman M, Van der Ven AJ, Hak E et al (2006) Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med 173:1348–1355

    Article  PubMed  CAS  Google Scholar 

  63. Pea F, Viale P, Furlanut M (2005) Antimicrobial therapy in critically ill patients. A review of pathophysiological conditions responsible for altered disposition and pharmacokinetic variability. Clin Parmacokinet 44:1009–1034

    Article  CAS  Google Scholar 

  64. Pea F, Viale P, Pavan F, Furlanut M (2007) Pharmacokinetic considerations for antimicrobial therapy in patients receiving renal replacement therapy. Clin Pharmacokinet 46: 997–1038

    Article  PubMed  CAS  Google Scholar 

  65. Munoz SJ, Stravitz RT, Gabriel DA (2009) Coagulopathy of acute liver failure. Clin Liv Dis 13:95–107

    Article  Google Scholar 

  66. Munoz S, Reddy KL, Lee W (2008) The coagulopathy of acute liver failure and implications for intracranial pressure monitoring. Neurocrit Care 9:103–107

    Article  PubMed  Google Scholar 

  67. De Gasperi, A. Corti, E. Mazza et al (2009) Acute liver failure: managing coagulopathy and the bleeding diathesis. Transpl Proc 41:1256–1259

    Article  Google Scholar 

  68. De Gasperi A, Amici O, Mazza E et al (2006) Monitoring intraoperative coagulation. Transpl Proc 38:815–817

    Article  Google Scholar 

  69. Singer AL, Olthoff KM, Haewon K et al (2001)A role of plasmapheresis in the management of acute hepatic failure in children. Ann Surg 234: 418–424

    Article  PubMed  CAS  Google Scholar 

  70. Shami V, Caldwell S, Hespenheide E (2003) Recombinant activated factor VII for the coagulopathy of fulminant hepatic failure compared with conventional therapy. Liver Transpl 9:138–143

    Article  PubMed  Google Scholar 

  71. Sembit S, Williams R. New liver support devices in ALF: a critical evaluation. Sem Liver Dis, 2003; 23: 283–294

    Article  Google Scholar 

  72. Barshes NR, Gay AN, Williams B et al (2005) Support for the acutely failing liver: a comprehensive review of historic and contemporary strategies. J Am Coll Surg 201:458–476

    Article  PubMed  Google Scholar 

  73. Karvellas CJ, Gibney N, Kutsogiannis et al (2007) Bench-to-bedside review: Current evidence for extracorporeal albumin dialysis systems in liver failure. Crit Care 11:205

    Article  Google Scholar 

  74. Liu JP, Gluud LL, Als-Nielsen B, Gluud C (2004) Artificial and bioartifcial support systems for liver failure. The Cochrane Database of Systematic Reviews, Issue 1, Art. No. CD003628 — Update 1 2009

    Google Scholar 

  75. McKanzie TJ, lillegard JB, Nyberg SL (2008) Artificial and bioartificial liver support. Semin liver Dis 28:210–217

    Article  Google Scholar 

  76. Mintzner S, William R (2003) Albumin dialysis MARS 2003: what evidence, how to procede? Liver International 23:3–4

    Article  Google Scholar 

  77. Lee KH, Lee MK H, Sutedja DS, Lim SG (2005) Outcome from MARS liver dialysis following drug induced liver failure. Liver International, 25: 973–977

    Article  PubMed  CAS  Google Scholar 

  78. Saliba F (2006) The MARS in the intensive care: a rescue therapy for patients with hepatic failure. Critical Care 10:118

    Article  PubMed  Google Scholar 

  79. Sauer IM, Goetz I, Walter G et al (2004) In vitro comparison of the MARS and SPAD. Hepatology 39:1408–1414

    Article  PubMed  CAS  Google Scholar 

  80. Rifai K, Ernst T, Kretschmer U et al (2003) Prometheus — a new extracorporeal system for the treatment of liver failure. J Hepatol 39:984–990

    Article  PubMed  CAS  Google Scholar 

  81. Ernst T, Kretschmer U, Hafer C et al (2005) The Prometheus device for extracorporeal support of combined liver and renal failure. Blood Purif 23:298

    Article  PubMed  Google Scholar 

  82. Demetriou A, Brown RS, Busuttil RW et al (2004) Prospective, randomized, multicenter, controlled trial of a Bioartificial Liver in treating acute liver failure. Ann Surg 239: 660–670

    Article  PubMed  Google Scholar 

  83. O’Grady J (2006) Personal view: current role of artificial liver support devices. Aliment Pharmacol Ther 23:1549–1557

    Article  PubMed  Google Scholar 

  84. Samuel D, Ichai P (2010) Prognosis indicator in acute liver failure: Is there a place for cell death markers? J Hepatol 53:593–595

    Article  PubMed  Google Scholar 

  85. Bechmann LP, Jochum C, Kocabayoglu P et al (2010) Cytokeratin 18-based modification of the Meld score improves prediction of spontaneous survival after acute liver failure. J Hepatol 53:639–647bl]References

    Article  PubMed  CAS  Google Scholar 

  86. Kramer DJ, Canabal JM, Arasi LC (2008) Application of intensive care medicine principles in the management of the acute liver failure patient. Liver Transplant 14:S85–S89

    Article  Google Scholar 

  87. Larson AM. (2010) Diagnosis and management of acute liver failure. Current Opinion in Gastroenterology 26:214–221

    Article  PubMed  Google Scholar 

  88. Stravitz RT, Lefkowitch JH, Fontana RJ et al (2011) Autoimmune acute liver failure: Proposed clinical and histological criteria. Hepatology 53:517–526

    Article  PubMed  CAS  Google Scholar 

  89. De Backer D, Marx G, Tan A et al (2011) Arterial pressure-based cardiac output monitoring: a multicenter validation of the third-generation software in septic patients. Intensive Care Med 37:233–240

    Article  PubMed  Google Scholar 

  90. Monnet X, Lahner D (2011) Can the “FloTrac” really track flow in septic patients? Intensive Care Med 37:183–185

    Article  PubMed  Google Scholar 

  91. Stravits TR, Kramer DJ (2009) Management of acute liver failure. Nature Rev Gastroenterol Hepatol 6:542–513

    Article  Google Scholar 

  92. Caironi P, Langer T, Taccone P et al (2010) Kidney instant monitoring (K.IN.G): a new analyzer to monitor kidney function. Minerva Anestesiol 76:316–324

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. 2nd Anesthesia and Critical Care Service, Transplant Department, Ospedale Niguarda Ca’ Granda, Milan, Italy

    Andrea De Gasperi, Patrizia Andreoni, Stefania Colombo, Paola Cozzi & Ernestina Mazza

Authors
  1. Andrea De Gasperi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Patrizia Andreoni
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Stefania Colombo
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Paola Cozzi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ernestina Mazza
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Andrea De Gasperi .

Editor information

Editors and Affiliations

  1. Critical Care Department Istituto Nazionale per lo Studio e la Cura dei Tumori, National Cancer Institute, Milan, Italy

    Biagio Allaria (Past Director) (Past Director)

Rights and permissions

Reprints and permissions

Copyright information

© 2012 Springer-Verlag Italia

About this chapter

Cite this chapter

De Gasperi, A., Andreoni, P., Colombo, S., Cozzi, P., Mazza, E. (2012). Acute Liver Failure in Intensive Care. In: Allaria, B. (eds) Practical Issues in Anesthesia and Intensive Care. Springer, Milano. https://doi.org/10.1007/978-88-470-2460-1_4

Download citation

  • DOI: https://doi.org/10.1007/978-88-470-2460-1_4

  • Publisher Name: Springer, Milano

  • Print ISBN: 978-88-470-2459-5

  • Online ISBN: 978-88-470-2460-1

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation