Acute liver failure for the intensivist

Acute liver failure (ALF) in the intensivist setting is the central focus, emphasizing early recognition and management. It's defined by encephalopathy or coagulopathy shortly after jaundice onset in individuals with previously healthy livers. The most common cause in high-income countries is paracetamol poisoning. Initial steps involve resuscitation, contacting a liver transplant service, and extensive blood testing. N-acetylcysteine (NAC) should be administered to all paracetamol overdoses and potentially all ALF patients, irrespective of etiology. Management includes careful glucose control, stress ulcer prophylaxis, and specialized low-protein feeding. Early dialysis is recommended, especially with elevated ammonia levels, and broad-spectrum antibiotics should be initiated in patients with grade three or higher encephalopathy. The King's College criteria aid in determining transplant eligibility, though some patients with paracetamol-induced ALF may recover without it.