Management

• General measures include fluid resuscitation and blood transfusion to keep Hb 7-10g/dl. The circulation is usually hyperdynamic and dilated; vasopressors may be needed to maintain an adequate BP.

• Correction of coagulopathy is often withheld as this provides a good guide to recovery or the need for transplantation. Use of fresh frozen plasma is restricted to patients who are bleeding or are about to undergo an invasive procedure.

• Adequate monitoring should be instituted if cardiorespiratory instability is present.

• Mechanical ventilation may be necessary if the airway is unprotected or respiratory failure develops. Lung shunts are frequently present, causing hypoxaemia.

• Infection is commonplace and is frequently either Gram positive or fungal. Clinical signs are often absent. Samples of blood, sputum, urine, wound sites, drain fluid, intravascular catheter sites and ascites should be sent for regular microbiological surveillance. Systemic antimicrobial therapy, with or without selective gut decontamination, has been shown to reduce the infection rate. Fungal infections are also well recognised. Some Liver Units give prophylactic antifungal therapy.

• Hypoglycaemia is a common occurrence. It should be frequently monitored and treated with either enteral (or parenteral) nutrition, or a 10-20% glucose infusion to maintain normoglycaemia.

• Renal failure occurs in 30-70% of cases and may necessitate renal replacement therapy. The incidence may be reduced by careful maintenance of intravascular volume. Vasopressin/terlipressin has also been used successfully for hepatorenal syndrome.

• Upper gastrointestinal bleeding is more common due to the associated coagulopathy. Prophylactic H2 blockers or proton pump inhibitors may be of benefit.

• W-acetylcysteine and/or epoprostenol improves O2 consumption. Though tissue hypoxia may be reduced by these drugs, particularly when vasopressor drugs are needed, outcome benefit remains unproved.

• Corticosteroids, prostaglandin E and charcoal haemoperfusion have not been shown to have any outcome benefit.

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