"improving intensive care in Scotland"

Liver failure

ICU care

Patients presenting to intensive care with acute liver failure should have:

Investigations

Full blood count, urea and electrolytes
Liver function and coagulation screen
Ca++, Mg++ and PO4-
HIV status
Hepatitis A,B and C, Epstein-Barr and cytomegalovirus serology
ABG and lactate
Blood urine and sputum culture
Group and save
ECG
Chest X-ray

Other investigations may be required if the cause is unknown

Paracetamol and salicylate levels
Auto-antibody screen
Caeruloplasmin and iron saturation (Wilson’s disease, haemochromatosis?)
Liver ultrasound scan
Imaging of hepatic vasculature (Budd-Chiari?)

Procedures

Radial arterial line
CVP line
Urinary catheter
Intubate and ventilate if GCS less that 8 (maybe if less than 10)
NGT if intubated (OGT if there is overt bleeding from any site)

Drug treatment

Sedation for intubated patients: Propofol and Alfentanil
Prophylaxis: All Intravenous
-Ceftriaxone 1g/day
-Amoxycillin 1g tid
-Fluconazole 400mg once then 200mg daily
Ranitidine 50mg tid
N-acetyl cysteine - if paracetamol is the cause (USA study in other groups awaited)
150mg/kg over 15min then 50mg/kg over 4hours then 100mg/kg over 16hours

Daily routine

FiO2 sufficient for PaO2 >10 KPa, ventilate to PaCO2 = 4.5 KPa
Head up position
Enteral feeding if possible
Blood sugar every 2 hours.
Twice daily FBC, PT, U&E, lactate

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