718	S. Kesavan and B. Ramachandran

90.1Concurrent Management of Hepatic Dysfunction

Step 1: Make a diagnosis

Total bilirubin of more than 4 mg/dL or ALT two times, normal for age, signiÞes hepatic dysfunction. The Pediatric Acute Liver Failure Study Group deÞned acute liver failure as follows:

¥Biochemical evidence of liver injury

¥No history of known chronic liver disease

¥Coagulopathy not corrected by vitamin K administration

¥International normalized ratio (INR) greater than 1.5 if the patient has encephalopathy or greater than 2.0 if the patient does not have encephalopathy

Step 2: Laboratory evaluation

¥Liver function test

ÐBilirubin is not usually high

ÐALT/AST can be in 10,000 IU/L (AST is usually more than ALT)

ÐProthrombin time and INR

¥Serum electrolytes

¥Hourly Blood glucose

¥Serum ammonia

Step 3: Treatment

¥Prevent further hepatic injury by avoiding hepatotoxic drugs.

¥Prevent and treat hypoglycemia and electrolyte abnormality.

¥Early nutrition should be with low-protein and high-calorie (120Ð150% requirement) enteral feeding.

¥Correct coagulopathy with blood products, only when there is bleeding or for invasive procedures.

¥Look for and treat raised intracranial hypertension as a part of hepatic encephalopathy:

ÐHead end elevation should be 30¡.

ÐAdequate sedation and analgesia is needed for children with hepatic encephalopathy and grade 3 or 4 encephalopathy.

ÐIntracranial pressure monitoring is considered for patients who are listed for liver transplantation.

ÐMannitol can be given for acute rise in intracranial pressure.

Ð3% saline is a better option in a child with shock and coexistent renal failure.

¥N-acetylcysteineÑthere is evidence favoring the use of N-acetylcysteine infusion in children with nonparacetamol liver failure, but the use in septic shock and ischemic hepatic dysfunction has not been studied. Ischemic hepatic dysfunction usually responds well to correction of the shock.

¥Lactulose, branched chain amino acids, enteral rifaximin and bowel wash have insufÞcient evidence for routine use.

¥Liver-support devices may be used as a bridge to transplantation or to help recovery of the ailing liver. They have limited role outside the

90 Multiorgan Failure	719

clinical trials. Two main categories of support devices are bioartiÞcial and artiÞcial (MARS).

¥Consider liver transplant if no improvement and where prognostic factors indicate a high likelihood of death. Liver dysfunction as the part of septic shock and MODS improves on correction of shock and rarely requires transplant.

Suggested Readings

1.Kortsalioudaki C, Taylor RM, Cheeseman P, Bansal S, Mieli-Vergani G, Dhawan A. Safety and efÞcacy of N-acetylcysteine in children with acute liver failure not caused by acetaminophen overdose. Liver Transpl. 2008;14(1):25Ð30.

N-acetylcysteine was associated with a shorter length of hospital stay, higher incidence of native liver recovery without transplantation, and better survival after transplantation.

2.Akcan-Arikan A, Zappitelli M, Loftis LL, Washburn KK, Jefferson LS, Goldstein SL. ModiÞed RIFLE criteria in critically ill children with acute kidney injury. Kidney Int. 2007;71(10):1028Ð35.

This article tested modified adult RIFLE criteria for pediatric age group. RIFLE criteria serve to characterize the pattern of acute kidney injury in critically ill children.

3.Bucuvalas J, Yazigi N, Squires RH Jr. Acute liver failure in children. Clin Liver Dis. 2006;149Ð68.

A review article on acute liver failure.

4.Strazdins V, Watson AR, Harvey B. Renal replacement therapy for acute renal failure in children: European Guidelines. Pediatr Nephrol. 2004;19:199Ð207.

This article discusses guidelines for renal replacement therapy in children.

Part XV

ICU Procedures

Rajesh Chawla and Sudha Kansal