Antibiotics in Acute Liver Failure (ALF)

Acute liver failure and hepatic encephalopathy in exertional heat stroke

A 31-year-old man was brought to Accident & Emergency after collapsing during a race. On presentation, the patient had a temperature of 41.7°C (rectal). External cooling was started immediately. The patient was intubated in view of a Glasgow Coma Scale of 7 and was transferred to theintensive therapy unit. Laboratory results revealed an acute kidney injury, rhabdomyolysis, disseminated intravascular coagulopathy and acute liver failure. The patient was encephalopathic, jaundiced and difficult to sedate. His liver function continued to deteriorate with alanine aminotransferase (ALT) levels reaching 9207 U/L. King's Hospital Liver Centre, London was contacted for a possible liver transplant, and they advised an infusion of N-acetylcysteine. The following day liver function tests improved; thus, transplantation was not performed. The patient failed multiple sedation holds and required a tracheostomy. He continued to spike a fever. Despite no source of sepsis being found, the patient remained on broad spectrum antibiotics to cover for any potential infective causes until day 27. After 15 days, the patient's encephalopathy gradually improved. He was weaned off the ventilator and underwent intense physiotherapy. The patient was discharged from hospital one month after admission.

Non-Intensive Care Unit Management of Acute Liver Failure

Acute liver failure (ALF) is an uncommon syndrome with a highly variable and unpredictable clinical course. The initial diagnostic evaluation is typically performed in a non-intensive care unit (ICU) setting, like the emergency department or general hospital ward. Prompt restoration of intravascular volume with intravenous fluids and correction of electrolyte, metabolic, and acid-base disturbances are important initial interventions in the management of ALF and can be safely accomplished in non-ICU settings in many patients. Similarly, therapies such as administration of N-acetylcysteine for acetaminophen-induced ALF and other cause-specific interventions can also be administered in non-ICU settings, thus minimizing delay.