Hepatic Failure/GI/Endocrine Emergencies

Patient Case

tion and is profoundly encephalopathic and unresponsive to pain on examination. An ICP monitor is placed,

which shows acute elevations of 30 mm Hg. Which is most appropriate for the acute management of ICP

elevations?

Management of hemodynamic instability

Patients should initially be resuscitated with 0.9% sodium chloride. Hypo-osmolar fluids including

lactated Ringer solution (273 mOsm/L) should be avoided, if possible, in patients with grade III

and grade IV encephalopathy because of the risk of cerebral edema. In addition, Plasma-Lyte (294

mOsm/L) could be used as an alternative to 0.9% sodium chloride (308 mOsm/L), given that it

is not hypo-osmotic and would provide a balanced solution to avoid the risk of hyperchloremic

metabolic acidosis.

Vasopressors should be used if fluid resuscitation fails to maintain a MAP greater than 75 mm Hg

or a CPP of at least 60 mm Hg.

Norepinephrine is the vasopressor of choice in patients requiring vasopressor support.

ii.

Use of vasopressin is controversial for patients with ALF who have high-grade encephalopathy.

One study of six patients with grade IV encephalopathy showed an increased ICP after 1 hour

of terlipressin (a synthetic vasopressin analogue), though systemic hemodynamics were not

significantly altered; however, a subsequent study did not show similar effects on ICP with

terlipressin. Because there have been no similar studies of vasopressin in patients with ALF,

its use in patients with ALF and high-grade encephalopathy should be cautioned. However, in

for patients with acute liver failure as well as the 2023 ACG ALF guidelines, vasopressin is

recommended to be added to norepinephrine with persistent shock, despite these concerns,

although both guidelines note a low level of evidence.

Management of coagulopathies

Although the INR may be elevated in patients with ALF, overall hemostasis is maintained through

compensatory mechanisms.

Because traditional measures of coagulation may be unreliable, guidelines suggest use of

viscoelastic testing such as thromboelastography over measuring INR, platelets, and fibrinogen

when available. In a small randomized trial of 60 cirrhotic patients, blood product transfusion was

significantly reduced when guided by thromboelastography compared with traditional measures

with no differences in bleeding complications. Unfortunately, these tests are not available at many

institutions and traditional measures are often still required.

In patients without acute bleeding or high-risk procedure such as ICP monitor placement, the

routine correction of coagulopathy is not supported. For instance, in patients with an elevated INR

without signs and symptoms of an acute bleed, INR should not be corrected using fresh frozen

plasma. Vitamin K (5–10 mg) may be administered because many patients with ALF are deficient in

vitamin K, further contributing to the coagulopathy of ALF. Intravenous administration is usually

recommended because subcutaneous administration of vitamin K can lead to erratic absorption,

and enteral absorption may also be unreliable.