Hepatic Failure/GI/Endocrine Emergencies
Encephalopathy
All medications that can cause sedation or confusion should be avoided (i.e., benzodiazepines,
anticholinergics, etc.).
ii.
Grade I encephalopathy can typically be managed with close monitoring and without
medication; grade IIβIV encephalopathy should be treated in an ICU setting, if possible.
iii.
Given its ability to decrease serum ammonia concentrations and experience with treatment
of hepatic encephalopathy in patients with cirrhosis, lactulose may be considered for patients
with ALF with low-grade encephalopathy (e.g., grade IβII). The recommended dose is 20β30
g three or four times daily to produce 2 or 3 soft stools a day.
| (a) | Despite its proposed benefits, retrospective data analyses of patients with ALF who |
|---|
receive lactulose therapy have not shown a benefit on encephalopathy or overall outcome.
| (b) | In addition, lactulose has the potential to cause abdominal distension, which could be |
|---|
a concern for liver transplantation. Moreover, overuse of lactulose has the potential to
cause intravascular depletion, which may further contribute to hemodynamic instability.
Therefore, its effects may be harmful in the acute setting, particularly for patients with
high-grade encephalopathy. In the 2023 ACG guidlines, the authors determine there is
inconclusive evidence to recommend for or against the use of lactulose in the treatment
of ALF.
| (c) | A similar recommendation is made for the role of rifaximin for the treatment of |
|---|
encephalopathy in the 2023 ACG guidelines; namely, that there is inconclusive evidence
for or against its use in this setting.
iv.
Some centers use high-flow continuous renal replacement therapy (CRRT) to remove ammonia
in patients with high-grade encephalopathy. CRRT has been associated with lower ammonia
levels within the first 3 days of ALF (median reduction in ammonia is 38% with CRRT
compared with 23% for intermittent RRT and 19% for no RRT). In the 2023 ACG guidelines,
early CRRT was recommended for patients with grade II encephalopathy or higher.
Patients with grade III and grade IV encephalopathy should be intubated for airway protection
and treated with minimal sedation to allow for more frequent neurologic assessments. If
sedation is necessary, propofol is typically used because it can reduce cerebral blood flow and
lower ICP.
Seizures
Seizures have the potential to increase ICP. Therefore, seizures should be controlled quickly
with short-acting benzodiazepines. If seizures persist, antiepileptic agents should be scheduled.
ii.
Use of prophylactic antiepileptics is not recommended. Studies have shown that use of
prophylactic phenytoin in patients with ALF has no impact on prevention of seizures, cerebral
edema, or overall survival.
Elevated ICPs
ICP should be kept less than 20β25 mm Hg while preserving CPP of at least 60 mm Hg.
ii.
Routine ICP monitoring has not been shown to reduce mortality in patients with ALF, and routine
placement of ICP monitors is not recommended. Clinicians may choose to place an ICP monitor
in patients with high-grade encephalopathy (grades III and IV) to provide close monitoring of
cerebral edema. In addition, some centers may use noninvasive ICP monitoring strategies such
as transcranial Doppler ultrasound to avoid the risks associated with more invasive ICP monitor
placement in these coagulopathic patients. However, these monitoring strategies should be
reserved for centers with large neurocritical care and neurosurgical experience.