• Twitter
  • Facebook
  • Vimeo
  • FCUS Courses
  • Register for FCUS Course
  • Login
Intensive Care Network
  • About Us
    • What is ICN
    • Our Team
  • Events
  • Podcast Series
    • Podcast by Topic
      • Airway Podcasts
      • Cardiac Podcasts
      • Career Podcasts
      • Conference Podcasts
      • Education Podcasts
      • Evidence Podcasts
      • GI/Renal Podcasts
      • Haem Podcasts
      • Metabolic Podcasts
      • Miscellaneous Podcasts
      • Neuro Podcasts
      • Paeds Podcasts
      • Respiratory Podcasts
      • Resuscitation Podcasts
      • Sepsis Podcasts
      • Toxicology Podcasts
      • Trauma Podcasts
      • Ultrasound Podcasts
    • Podcast by Specialty
      • Anaesthetics
      • Emergency
      • ICU
      • Prehospital
    • SMACC
    • ICN
    • Jellybean
    • CICM ASM
  • Blog
  • Resources
    • Clinical Cases
    • Fav Posts/Other Sources
    • Game Changing Evidence
    • Radiology
      • ICU Radiology
    • Simulation Resources
    • Ultrasound
      • Lung Ultrasound
  • EXAMHELP
    • ANAESTHETICS PRIMARY
    • ANZCA FELLOWSHIP
    • CICM Fellowship
    • EMERGENCY PRIMARY
    • ICU Primary Exam
    • PAEDS FELLOWSHIP
  • Contact Us

Acute liver failure: NEJM Critical Care Challenge Case 5

Home Acute liver failure: NEJM Critical Care Challenge Case 5

In this Christmas episode of the NEJM’s evolving case series looking at common problems in critical care, we turn our attention from ventilatory stategies in ARDS to the management of acute liver failure in an elderly man admitted to the ICU with severe sepsis.

Acute liver failure

[az_box_icon animation_loading=”yes” animation_loading_effects=”move_left” icon=”font-icon-vcard” title=”Summary of Case” position=”left”] [/az_box_icon]

A 77-year-old man whose medical history includes treated hypertension and hypercholesterolemia, previous heavy alcohol intake, and mild cognitive impairment is admitted to the intensive care unit (ICU) of a university hospital from the operating room after resection of the rectosigmoid colon with closure of the rectal stump and formation of an end colostomy performed for fecal peritonitis due to a perforated sigmoid colon. On arrival in the ICU, he was in septic shock. He received fluid resuscitation with Hartmann’s solution and 5% human albumin solution. His blood pressure was supported with a norepinephrine infusion, and he was treated with ampicillin, amikacin, and metronidazole. He underwent mechanical ventilation with the use of a lung-protective strategy and was sedated with propofol.

The postoperative analgesia was a fentanyl infusion, with the dose adjusted by the nurses, and 1 g of intravenous acetaminophen every 6 hours.

Over the next 2 days, his condition stabilized, but on the 4th day after surgery, the alanine aminotransferase (ALT) level had increased from within the normal range (7 to 55 U per liter) at admission to 3402 U per liter, and the aspartate aminotransferase (AST) level had increased to 5322 U per liter (normal range, 8 to 48 U per liter). The international normalized ratio was 4.3, and the bilirubin level was 3.8 mg per deciliter (65 µmol per liter) (normal range, 0.1 to 1.0 mg per deciliter [1.7 to 17.0 µmol per liter]).

[az_box_icon animation_loading=”yes” animation_loading_effects=”move_left” icon=”font-icon-question” title=”Question” position=”left”] [/az_box_icon]

Which of the following strategies would you use to treat this patient’s acute liver failure?

1. Reduce the acetaminophen dose to 1 g every 12 hours and continue supportive therapy

2. Cease acetaminophen and continue supportive therapy

3. Cease acetaminophen, start treatment with acetylcysteine and continue supportive therapy

4. Continue acetaminophen, since it is probably not associated with this mans liver failure.

Once youve decided, the results can be found here.

Share this
The Man Behind The Beans: Doug LynchGame Changing Evidence: The Guts and the Glory
IPSN – Intensivist Parent Support Network WIN – Women in Intensive Care Network ICN UK ICN NZ ICN WA ICN VIC ICN NSW ICN QLD The ICN Story The Team Jellybean Podcasts ICN Blog SMACC Video SMACC Audio Video ECG Simulator by aclsmedicaltraining BASIC SCIENCE CLINIC Simulation Game Changing Evidence ICU Radiology Echo Guide ECHO Cases Clinical Cases EXAMHELP Jellybean Podcasts ICN Blog SMACC Video SMACC Audio Video CICM Fellowship ANZCA FELLOWSHIP PAEDS FELLOWSHIP EMERGENCY PRIMARY ANAESTHETICS PRIMARY End-o-bed-o-gram

  • About
    •  What is ICN
    •  The Team
    •  ICN NSW
    •  ICN QLD
    •  ICN VIC
    •  ICN WA
    •  ICN NZ
    •  ICN UK
  • Resources
    •  Lung US
    •  Exam Help
    •  Clinical Cases
    •  Echo Cases
    •  Echo Guide
    •  ICU Radiology
    •  Game Changing Evidence
    •  ICN Metafeed
    •  Simulation Resouces
  • Media
    •  SMACC Posters
    •  Audio
    •  Video
    •  Pecha Kuchas
  • Upskill
    •  Clinical Cases
    •  Echo Cases
    •  ICU Radiology
  • Exam Help
    •  End-o-Bed-o-Gram
    •  ICU Primary Exam
    •  CICM Fellowship
    •  ANZCA Fellowship
    •  Paeds Fellowship
    •  Emergency Primary
    •  Anaesthetics Primary

® 2021 The Intensive Care Network || All rights reserved || Disclaimer || Site Map || Contact ICN Support

Log in with your credentials

or     Create an account

Lost your password?

Forgot your details?

I remember my details

Create Account