Case 2: Management

Interval History:


She is admitted to the medical floor. Overnight, the patient becomes more confused. On examination, she is lethargic and oriented only to self. She has developed asterixis. You decide to repeat her basic labs.

Further Diagnostic Testing:

Here are the results of the repeat labs, 6 hours later

You decide to get some imaging and order an abdominal ultrasound. Here are the findings:

  • Echogenic liver, compatible with nonspecific hepatic parenchymal disease, including but not limited to hepatic steatosis.
  • Partially visualized right-sided pleural effusion
  • Patent hepatic vasculature


Based on these results, what are the 3 best next steps in management?
Start intravenous N-acetylcysteine (NAC)
Correct! Begin NAC promptly in all patients where the quantity of acetaminophen ingested, serum drug level or rising aminotransferases indicate impending or evolving liver injury.
ICU Evaluation
Correct! Patients with acute liver failure need close laboratory and neurological monitoring that should be performed in the ICU. Intracranial pressure monitoring is recommended in ALF patients with high grade hepatic encephalopathy, which can be performed non-invasively at certain centers. In the absence of ICP monitoring, frequent (hourly) neurological evaluation is recommended to identify early evidence of intracranial hypertension.  Trending an arterial ammonia level in acute liver failure is one of the few times this laboratory result is clinically helpful, as it can directly correlate with the degree of cerebral edema.
Empiric Antibiotics
Incorrect. Prophylactic antibiotics and antifungals have not been shown to improve overall outcomes in ALF and therefore cannot be advocated in all patients, particularly those with mild hepatic encephalopathy. Try again!
Transfuse FFP to Improve INR 
Incorrect. The routine use of fresh frozen plasma and other coagulation factors is not supported, and should be limited to specific situations, such as peri-procedurally or in the setting of active bleeding. Try again!
Begin Liver Transplant Evaluation
Correct! Contact with a transplant center and plans to transfer appropriate patients with ALF should be initiated early in the evaluation process.
Incorrect. Consider for treatment only in autoimmune hepatitis. Corticosteroids should not be used to control elevated ICP in patients with ALF. Try again!


Which exam signs or labs in this patient indicate a poor prognosis?
pH 7.28
Correct! Per the King’s College Criteria, pH < 7.3 indicates poor prognosis.
INR 2.5
Incorrect. Per the King’s College Criteria, INR > 6.5 indicates poor prognosis. Try again!
Grade 3 or 4 Hepatic Encephalopathy
Correct! Per the King’s College Criteria, Grade 3 or 4 Hepatic Encephalopathy indicates poor prognosis. 
Creatinine 0.74
Incorrect. Per the King’s College Criteria, Creatinine > 3.4 indicates poor prognosis. Try again!

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