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All YPMP ALF patients are monitored in the LICU for 3–5 days after ingestion and nursed in 30-degree head elevated position.
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Patients are assessed for clinical parameters especially for liver, cardiac, and neurotoxicity with hourly assessment for HE and pupillary reflexes and continuously monitored for vital parameters and electrocardiography (ECG).
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Gastric lavage is done without any additives for patients presenting within 24 h. A nasogastric tube is used for gastric decompression in patients with HE.
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Patients with HE > grade 3 are electively sedated and intubated. pCO2 is maintained between 30 and 35 mm Hg.If raised intracranial pressure (ICP) is suspected, optic nerve diameter, reverse jugular oxygen saturation, transcranial Doppler or CT brain is done. Direct ICP monitoring may be done very selectively.Standard protocols for managing raised ICP are followed including mannitol, thiopentone and others.
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Fluid intake, output and balance are monitored hourly, serum electrolytes, acidosis, ammonia and lactate are monitored 2nd hourly using arterial blood gases (ABGs) and corrected appropriately. Serum sodium is maintained between 145 and 150 meq/dl.
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Blood glucose is monitored 6 hourly and corrected as required.
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Advanced hemodynamic monitoring using arterial and central venous lines and continuous pulse contour cardiac output (PiCCO) monitor to record cardiac output (CO), systemic vascular resistive index (SVRI), stoke volume variance (SVV), intrathoracic blood volume index (ITBVI) and inferior vena cava (IVC) assessment are done in patients with HE, SIRS, high lactate or acidosis and used to titrate fluids and ionotropes.
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Laboratory tests including complete blood counts, amylase, lipase, liver function tests (LFT), renal function tests, PT-INR are monitored twice a day until recovery.
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Chest X-ray, abdominal ultrasonography (USG) and 12-lead ECG and echocardiogram (ECHO) are done on admission. A cardiologist is consulted for suspected cardiotoxicity.
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Sequential organ failure assessment (SOFA) score is calculated on admission and daily.
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Awake patients are given high-carbohydrate, high-protein, low-fat or no-fat diet with supplementary intravenous dextrose and multi-vitamins. Patients with ≥ grade 2 HE or high dose inotropes are kept nil per orally (NPO).
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N-acetylcysteine (NAC) is given at 100 mg/kg IV over 24 h for 5 days.
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Prophylactic antimicrobials (ceftriaxone + sulbactam) and antifungals (fluconazole) are used in patients with HE, high lactate, or SIRS.
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Lactulose and rifaximin are given to patients with HE, not on CVVHDF.
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Patients with PT-INR > 2 are given vitamin K 10 mg IV for 3 days.
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Fresh frozen plasma (FFP), cryoprecipitate, tranexamic acid and platelet transfusions are used only for bleeding, guided by coagulation parameters (PT-INR, fibrinogen levels and platelet counts) and thromboelastography (TEG).
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CVVHDF is done for patients with renal failure related indications, severe lactic acidosis (despite adequate resuscitation) or as ammonia lowering therapy for two consecutive arterial ammonia values > 150 μmol/l or any single value > 200 μmol/l. Dialysate dose of 35 ml/kg/hr is used, although higher doses (60–100 ml/kg/hr) may be used for inadequate ammonia clearance.
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Three sessions of daily plasmapheresis are performed in all patients after admission except those without any evidence of SIRS. Replacement dose was calculated using the apheresis formula.
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Patients with suspected suicidal ingestion undergo psychiatry consultation before transplant when feasible but before discharge in all cases.
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Evaluation and preparation for liver transplantation is initiated on admission. All patients meeting King's College criteria (KCC) or national health services blood and transfusion services (NHSBT) ALF criteria (Kathy) are listed as ‘super-urgent’ with the Zonal Transplant Coordination Committee (ZTCC), Mumbai.5,6 Living donor evaluation is done and approval from local or state authorization committee obtained. Transplant is performed only for patients with worsening despite medical therapy if no contraindications to transplant existed (irreversible neurological damage, systemic infection) and after recovery from bone marrow and cardiotoxicity.
