Hepatic Failure/GI/Endocrine Emergencies

Guidelines recommend an INR correction to about 1.5 for clinically significant bleeding.

ii.

If a fresh frozen plasma infusion alone does not adequately lower INR, recombinant activated

factor VII (rFVIIa) may be administered. In a small nonrandomized study of 15 patients

with fulminant hepatic failure, administration of rFVIIa at a dose of 40 mcg/kg temporarily

improved coagulation parameters (i.e., INR less than 1.6) compared with patients receiving only

fresh frozen plasma (100% vs. 0%, p<0.002). Although the improvements in coagulation were

only temporary, patients in the rFVIIa group were able to have invasive procedures performed

(e.g., ICP monitors placed) more often than were patients in the control group (100% vs. 38%,

p=0.03).

iii.

Data are limited on use of prothrombin complex concentrate (PCC) for reversing coagulopathy

in ALF; however, it appears to be similar in efficacy to rFVIIa. A retrospective study in patients

with cirrhosis found similar rates of INR reversal (1.5 or less) in patients who received either

PCC (80%; p=0.03) and rFVIIa (87%; p=0.04), compared with FFP (27%). Therefore, PCC may

be an option in cases for which the goal is to limit volume associated with FFP; however, INR-

based dosing limits this use, and further study is warranted.

To reduce the risk of spontaneous intracranial hemorrhage, platelet transfusions should be provided

if the count drops to less than 15,000–20,000/mm3 in the absence of bleeding.

If clinically significant bleeding occurs, patients should be transfused to a target platelet count

greater than 50,000/mm3.

ii.

For invasive procedures, platelet counts should be 50,000–70,000/mm3 to prevent bleeding,

though thromboelastography data analyses suggest that a target of 100,000/mm3 is ideal.

Patients with ALF should be evaluated for venous thromboembolism prophylaxis based on

traditional risk assessments (e.g., thrombocytopenia, recent and/or active bleeding, etc). Venous

thromboembolism prophylaxis should not be withheld due to elevated INR because INR often

overestimates hypercoaguability in patients with ALF. Selection of agent for prophylaxis is unclear.

No studies have compared low-molecular-weight heparin with unfractionated heparin in patients

with ALF; however, most studies of patients with cirrhosis support the use of LMWH, though the

control group is no-prophylaxis.

Histamine-2 receptor antagonists or PPIs should be initiated in patients with ALF to reduce the

incidence of spontaneous GI bleeding.

Management of infectious complications

Antimicrobial prophylaxis is often given because infection remains the primary cause of death in

patients with ALF. However, data analyses are limited on the benefit of antimicrobial prophylaxis

in ALF. A retrospective cohort study of 1551 patients with ALF showed that prophylactic antibiotic

therapy did not reduce the incidence of bloodstream infections (12.8% in the prophylaxis group vs.

15.7% in the non-prophylaxis group, p=0.12) and did not reduce 21-day mortality.

The 2023 ACG guidelines recommend against the routine use of prophylactic antimicrobials.

Patients should be monitored closely for infection through surveillance cultures, and antimicrobials

should be initiated promptly if the patient has any signs or symptoms of a systemic infection.

Empiric administration is recommended for any of the following scenarios:

Positive surveillance cultures

ii.

Progression to higher-grade encephalopathy

iii.

Refractory hypotension

iv.

Development of systemic inflammatory response syndrome (SIRS) criteria