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Acute Liver Failure Medication

  • Author: Gagan K Sood, MD; Chief Editor: BS Anand, MD  more...
Updated: Feb 04, 2016

Medication Summary

Multiple medications may be necessary in patients with acute liver failure because of the wide variety of complications that may develop from fulminant hepatic failure. Decreased hepatic metabolism and the potential for hepatotoxicity become central issues. In patients with liver failure from Amanita phalloides or acetaminophen toxicity, antidotes that effectively bind or eliminate the relevant toxins are essential.



Class Summary

Antidotes neutralize toxic agents and neutralize or counteract any form of poisoning.

Penicillin G (Pfizerpen)


Intravenous penicillin G is the drug of choice for the treatment of mushroom poisoning from Amanita phalloides. Its mode of action is unclear in this setting.

Silibinin (Silibinin Plus)


Silibinin is a water-soluble derivative of silymarin, which is the active ingredient in the herbal preparation milk thistle. This agent possesses antioxidant properties that may benefit liver disease management.

Activated charcoal (Actidose-Aqua, Liqui-Char, CharcoAid)


In patients who have recently ingested A phalloides, activated charcoal may bind the toxin and prevent absorption.

N-acetylcysteine (Mucomyst, Mucosil)


N-acetylcysteine is the drug of choice in acetaminophen overdose. N-acetylcysteine provides reducing equivalents to help restore depleted intrahepatic glutathione levels.


Osmotic Diuretic

Class Summary

Intracranial hypertension in acute liver failure is managed initially by the use of osmotic diuretics such as mannitol.

Mannitol (Osmitrol)


Osmotic diuresis with intravenous mannitol is effective in the short term for decreasing cerebral edema. Administration of intravenous mannitol (in a bolus dose of 0.5-1 g/kg or 50-100 g) is recommended to treat intracranial hypertension in acute liver failure. The dose may be repeated once or twice, as needed, provided that serum osmolality has not exceeded 320 mOsm/L. Volume overload is a risk with mannitol use in patients with renal impairment and may necessitate the use of dialysis to remove excess fluid.


Barbiturate Agents

Class Summary

Barbiturate agents such as thiopental and pentobarbital may be considered when severe intracranial hypertension does not respond to other measures. Administration has been shown to effectively decrease intracranial pressure (ICP). Significant systemic hypotension frequently limits their use and may necessitate additional measures to maintain adequate mean arterial pressure.

Pentobarbital (Nembutal)


Pentobarbital is a short-acting barbiturate with sedative, hypnotic, and anticonvulsant properties. It may be used at high dosages to induce barbiturate coma for the treatment of refractory increased ICP. The recommended dose is 3-5 mg/kg intravenously as a loading dose, followed by infusion at 1-3 mg/kg/h intravenously.

Thiopental (Pentothal)


Thiopental is an ultra–short-acting central nervous system depressant that decreases intracranial pressure. The recommended dose of thiopental for intracranial hypertension is 5-10 mg/kg as a loading dose, followed by an infusion of 3-5 mg/kg intravenously.



Class Summary

As patients with fulminant hepatic failure drift deeper into coma, the ability to protect their airway from aspiration decreases. Short-acting benzodiazepines in low doses may be used before intubation.



Midazolam is a shorter-acting benzodiazepine sedative-hypnotic useful in patients requiring acute and/or short-term sedation. Midazolam is used for sedation for mechanically ventilated patients. It is given through continuous intravenous infusion for sedation of intubated and mechanically ventilated patients.


Anesthetic Agents

Class Summary

Anesthetic agents such as propofol have sedative and hypnotic effects that are used for induction.

Propofol (Diprivan)


Propofol is a sedative-hypnotic that decreases the cerebral blood flow and intracranial hypertension. Propofol (50 mcg/kg/min) may be initiated before intubation and continued as an infusion.

Contributor Information and Disclosures

Gagan K Sood, MD Associate Professor, Department of Medicine and Surgery, Baylor College of Medicine

Gagan K Sood, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association

Disclosure: Nothing to disclose.


Mark S Slabinski, MD, FACEP, FAAEM Vice President, EMP Medical Group

Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Ohio State Medical Association

Disclosure: Nothing to disclose.

Steven A Conrad, MD, PhD Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center

Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Lemi Luu, MD, RDMS, FACEP, FAAEM Attending Physician, Department of Emergency Medicine, Bridgeport Hospital, Yale-New Haven Health System

Lemi Luu, MD, RDMS, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Institute of Ultrasound in Medicine

Disclosure: Nothing to disclose.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.


David Eric Bernstein, MD Director of Hepatology, North Shore University Hospital; Professor of Clinical Medicine, Albert Einstein College of Medicine

David Eric Bernstein, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Oscar S Brann, MD, FACP Associate Clinical Professor, Department of Medicine, University of California at San Diego; Consulting Staff, Mecklenburg Medical Group

Oscar S Brann, MD, FACP is a member of the following medical societies: American Gastroenterological Association

Disclosure: Nothing to disclose.

Blake A Jones, MD New Hampshire Gastroenterology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Carin M Van Gelder, MD Assistant Professor, Department of Emergency Medicine, Yale University; EMS Medical Director, NHSHP and EMS Physician, SHARP Team; Attending Physician, Emergency Medicine, Yale-New Haven Medical Center

Carin M Van Gelder, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Massachusetts Medical Society, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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Ultrasonogram shows a hyperechoic mass representing hepatocellular carcinoma.
Subacute subdural hematoma with extension into the anterior interhemispheric cistern. Note that the sutures do not contain the spread of these hemorrhages.
Table. Grading of Hepatic Encephalopathy
Grade Level of Consciousness Personality and Intellect Neurologic Signs Electroencephalogram (EEG) Abnormalities
0 Normal Normal None None
Subclinical Normal Normal Abnormalities only on psychometric testing None
1 Day/night sleep reversal, restlessness Forgetfulness, mild confusion, agitation, irritability Tremor, apraxia, incoordination, impaired handwriting Triphasic waves (5 Hz)
2 Lethargy, slowed responses Disorientation to time, loss of inhibition, inappropriate behavior Asterixis, dysarthria, ataxia, hypoactive reflexes Triphasic waves (5 Hz)
3 Somnolence, confusion Disorientation to place, aggressive behavior Asterixis, muscular rigidity, Babinski signs, hyperactive reflexes Triphasic waves (5 Hz)
4 Coma None Decerebration Delta/slow wave activity
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