General management

Hypoglycemia is common. It arises as a consequence of impaired circulating insulin, impaired gluconeogenesis, and an inability to mobilize glycogen stores. Hypophosphatemia and hypomagnesemia are also frequent problems, particularly when urine output is maintained. A metabolic acidosis may be seen; this carries a poor prognosis and prompts consideration of transplantation. The etiology is multifactorial, relating to hepatic dysfunction, impaired lactate metabolism, and also tissue hypoxia in patients who are inadequately volume resuscitated. Patients with AHF are at increased risk of infections, both bacterial and fungal; this appears to be related to compromised immune function with impaired neutrophil and Kupffer cell function and deficiency of opsonins. Bacterial infection rates of up to 80 per cent occur within a few days of admission. Some centers use prophylactic antibiotic regimens; however, a high index of suspicion should be maintained in all patients. All patients are given local oral antifungal treatment. The development of a coagulopathy is inherent to the disease process and is a good prognostic indicator. Therefore fresh frozen plasma is not given unless the patient is actively bleeding. Quantitative and qualitative defects in platelet function are observed; infusions are given as clinically required. Gastrointestinal bleeding is rare, but prophylaxis may be undertaken with agents such as sucralfate.

As in all critically ill patients, feeding should be instituted as soon as possible. In nearly all patients enteral nutrition is tolerated. In AHF a low-protein low-sodium diet is not appropriate; calories and protein should be given as the clinical situation dictates.

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