›Supportive care bundle
›Fluids and electrolytes
›Isotonic crystalloid for hypovolemia
›Potassium replacement as needed
›Antiemetics
›Ondansetron 4 mg IV or PO
›Repeat dosing every 6 to 8 hours as needed
›Nutrition
›Early oral intake as tolerated
›Dextrose-containing fluids if poor intake
›Medication avoidance
›Alcohol abstinence
›Avoid unnecessary hepatotoxic agents
›Acetaminophen avoidance unless supervised low-dose plan
Antidotes and etiology-directed therapy
›N-acetylcysteine
›Acetaminophen toxicity treatment
›Initiate immediately when toxic ingestion suspected (Class I)
›Initiate when level pending and timing unclear (Class I)
›IV protocol (21-hour)
›Loading dose 150 mg/kg over 1 hour
›Maximum 15 g
›Second infusion 50 mg/kg over 4 hours
›Third infusion 100 mg/kg over 16 hours
›Continuation criteria
›Continue beyond 21 hours if ALT rising
›Continue beyond 21 hours if INR elevated
›Continue beyond 21 hours if acetaminophen detectable
›Non-acetaminophen acute liver failure
›Consider early use in acute liver failure (Class IIa)
›Greatest benefit reported in early encephalopathy grades
›Suspected HSV hepatitis
›Acyclovir
›Initiate empiric acyclovir in fulminant hepatitis with pregnancy or immunocompromised risk (Class IIa)
›Dosing 10 mg/kg IV every 8 hours
›Renal adjustment required
›Severe acute hepatitis B
›Nucleos(t)ide analog therapy
›Consider tenofovir or entecavir in severe or fulminant acute HBV (Class IIa)
›Specialist coordination recommended
›Cholangitis or biliary obstruction
›Antibiotics for cholangitis physiology (Class I)
›Piperacillin-tazobactam 4.5 g IV every 6 hours
›Ceftriaxone 2 g IV daily
›Add metronidazole 500 mg IV every 8 hours
›Severe sepsis option
›Meropenem 1 g IV every 8 hours
›Source control pathway
›ERCP urgency for ascending cholangitis
›Surgical consultation for cholecystitis overlap
Coagulopathy and bleeding
›Coagulopathy principles
›INR elevation without bleeding
›No routine correction before low-risk care (Class IIb)
›Vitamin K trial when malnutrition or cholestasis possible
›Phytonadione 10 mg IV once daily for up to 3 days
›Active bleeding or urgent procedure
›FFP guided by bleeding risk and procedure plan (Class IIa)
›Platelets for severe thrombocytopenia with bleeding
›Cryoprecipitate for low fibrinogen with bleeding
Encephalopathy and cerebral edema risk
›Encephalopathy management
›Lactulose
›Initiate for encephalopathy when airway protected (Class I)
›Dose 20 to 30 g PO or via NG
›Titrate to 2 to 3 soft stools daily
›Rifaximin
›Add-on for recurrent or persistent encephalopathy (Class IIa)
›Dose 550 mg PO twice daily
›Avoidance
›Minimize sedatives
›Avoid NSAIDs
›Cerebral edema precautions in acute liver failure
›Head of bed elevation
›30 degrees
›Neutral neck position
›Hypercapnia avoidance
›pCO2 target 35 to 40 mmHg when intubated
›Hyperosmolar therapy triggers
›Pupillary changes
›Cushing physiology
›Rapid mental status decline
›Hypertonic saline option
›3% saline bolus 2 ml/kg
›Sodium target 145 to 155 mmol/l
›Mannitol option
›0.5 to 1 g/kg IV bolus
›Avoid if renal failure or hypotension
›Pruritus management
›Cholestyramine
›4 g PO once to twice daily
›Separate from other meds by 4 hours
›Antihistamines
›Limited efficacy for cholestatic itch
›Sedation risk with encephalopathy
›Pain management
›Avoid NSAIDs in liver failure risk
›AKI risk
›Bleeding risk
›Opioids
›Lowest effective dose
›Monitor mental status closely