University Hospital of Wales Paediatric Intensive Care Unit Guideline Printed on Wed 23-jul-08
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Last updated December 9, 2014 1:59 PM

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University Hospital of Wales Heath Park
Cardiff
CF14 4XW
02920 747747

Liver Failure

All cases should be discussed with the liver team at Birmingham Children's Hospital or King's College Hospital at an early stage

Evaluation

  1. Full history including information on:
  2. IV injections, needles and needlestick injury
  3. Infusions of blood products
  4. Contact with jaundice
  5. Family history of liver disease
  6. Sexual contacts
  7. Parents drug habits and medications
  8. Patients' medications or other suspect poisons (e.g. mushrooms)

Examination

Pay particular attention to and record:
Degree of encephalopathy:

State of hydration

Evidence of spontaneous bleeding
Evidence of chronic liver disease
Mark upper and lower margins of liver onto abdomen with waterproof marker.


Investigations

Blood

Urine

If out of hours please save the above samples

If patient >3 years old

Other

Management

All patients should have minimal handling and be treated as potentially infectious (gloves and aprons). Nurse head up 10-20 degrees

Monitor

  1. Blood pressure, heart rate, ECG
  2. CVP (4-8 mmHG)
  3. Core-toe temperature
  4. Urine output by catheter
  5. Cutaneous oximetry
  6. Degree of encephalopathy
  7. Blood glucose 4 hourly
  8. Gastric pH by nasogastric aspiration 6 hourly

 

Fluid balance

1. Restrict to reduce intracranial pressure
2. Maintain circulating volume with colloid

Fluids are restricted to 50-75% maintenance (depending on CVP and ICP)
Guidelines:

Infants - 2 years 70 ml/kg/day
2 - 5 years 60 ml/kg/day
5 - 10 years 50 ml/kg/day
>10 years 40 ml/kg/day

 

Electrolytes:

Sodium replacement 50% of maintenance or none depending on electrolytes and hydration.
Potassium 2-4 mmol/kg/d depending on electrolytes
Maintain urine output (0.5-2 mls/kg/hour)

Avoid using FFP in early stages, as coagulation is good guide to prognosis.

FFP may be required for procedures or for active bleeding.

Baseline drugs


Vitamin K

<1 year 2.5 mgs/day IV 
>1 year 5 mg/day IV  IV Vitamin K.
>10 years 10 mgs/day IV

Give Vit K for 3 consecutive days

Ranitidine - 1-3 mgs/kg/dose TDS
Lactulose - 2-4 rnls/kg/dose TDS

Low protein diet if indicated
N-acetylcysteine
Antibiotics and Antifungal therapy

General PICU management

Treatment principles of raised ICP (in order of importance)