Acute liver failure in Children : Paediatrics : Summary

Acute liver failure

         Dr Sara Malik

Basic concept: patchy or confluent massive  hepatic necrosis leading to hepatic function deterioration

Definition:

1.biochemical evidence of liver injury  <8 weeks duration

2.no evidence of chronic liver disease

3.PT>15 sec ,INR>1.5  + hepatic encephalopathy

4. PT>20  sec ,INR>2  regardless hepatic encephalopathy

History :

Previously healthy child with progressive jaundice ,fever,anorexia ,vomiting    &

Symptoms of hepatic encephalopathy (Infants -----irritability ,sleep disturbance cycle .

 child ----asterexis)

Examination 

Jaundice

Mucocutaneous bleed

Fluctuation of GCS due to hepatic encephalopathy

Rapid decrease in liver size without clinical improvement (omnious sign)

Signs of respiratory failure in end stage

Laboratory findings:

liver enzyme study	ALT markedly raised Serum bilirubin increased
Synthetic activity of liver	PT & APTT increased ,not improving after vit k administration Basal sugar level …low Serum ammonia normal or increased
Complications of ALF	1.CB(TLC) and complete urine examination  for sepsis 2 .seum electrolytes for dilutional affect on sodium & potassium 3.ABG -----------------metabolic acidosis  & later respiratory alkalosis 4.renal function test for renal dysfunction

                                                 Management

1.prevention of hypoglycaemia

2. correction of coagulopathy…..inj vit k parenterally or later FFP (FFPS may be needed upto 6hrly) (keep NG passed in stomach to watch for hidden GI bleeding)

3.correction of dehydration ..isotonic fluids

4. Clear the gut of free ammonia by giving sodium benzoate 1ml/Kg/ per Ng  8 Hrly

5. clear the gut off ammonia producing bacteria by giving tablet Rifixamine (10 mg per kg)

6. In grade- I encephalopathy , Flumazenil 0.01mg/kg/ O.D has a good role in reversal of encephalopathy.

7. Prevention of constipation by giving syp lactulose per Ng X 8Hrly.

8. If there is acute liver failure of infancy then, antifungal prophylaxis is indicated.
Syp or inj Fluconazole ( load with 12mg per kg , then 6mg/kg O.D after 24 hours of first dose)

Cause management:

N –acetyl cysteine	Acetaminophen poisoning
Acyclovir	Herpes simplex viral infection
Entacavir/ Lamividine	Hep B virus
Prednisolone	Autoimmune hepatitis
pencillamine	Wilson disease

Complications management:

1.Cerebral edema prevention by head up,restrict fluids

Mechanical ventilation & oxygen supplementation may be required

Do not use sedatives

Opiates are better than benzodiazepenes

2. Prevent sepsis by broad spectrum antibiotics as gram positive organisms are most common including Staphylococcus aureus,staphylococcus epidermidis

3.prevent gastrointestinal bleeding by H₂ blockers or PPI

Life saving treatment: If advanced liver failure ,liver transplantation required

 One of the first duties of the physician is to educate the masses not to take medicine.