Acute Liver Failure Medication
- Author: Gagan K Sood, MD; Chief Editor: BS Anand, MD more...
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.
Antidotes neutralize toxic agents and neutralize or counteract any form of poisoning.
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 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.
In patients who have recently ingested A phalloides, activated charcoal may bind the toxin and prevent absorption.
N-acetylcysteine is the drug of choice in acetaminophen overdose. N-acetylcysteine provides reducing equivalents to help restore depleted intrahepatic glutathione levels.
Intracranial hypertension in acute liver failure is managed initially by the use of osmotic diuretics such as mannitol.
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 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 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 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.
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 such as propofol have sedative and hypnotic effects that are used for induction.
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.
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|Grade||Level of Consciousness||Personality and Intellect||Neurologic Signs||Electroencephalogram (EEG) Abnormalities|
|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|