Liver Failure
Definition
Loss of liver function with evidence of acute liver injury of typically less than 8 weeks duration
No evidence of chronic liver disease
Hepatic-based coagulopathy
PT >15 seconds or INR > 1.5 not corrected by vitamin K WITH hepatic encephalopathy*
PT > 20 seconds or INR > 2 WITH OR WITHOUT hepatic encephalopathy*
Biochemical evidence of acute liver injury
Indirect or direct hyperbilirubinemia and/or
Transaminitis (elevated alanine transaminase (ALT) and/or aspartate transaminase (AST))
* PT (prothrombin time), INR (international normalized ratio)
Tips for Documenting Liver Failure
“Liver Disease/Liver Dysfunction” are broad terms; liver/hepatic failure is more specific and should be documented if the above criteria are met
Link liver failure to its etiology IF known:
Hypoperfusion
Toxin/drug related
Infectious
Immunologic
Metabolic disorderNearly 50% of acute liver failure cases in children are idiopathic, where no identifiable source can be found
CHRONIC liver failure is defined as loss of liver function of greater than 8 weeks duration
Document linkage when associated comorbidities present such as:
Cerebral edema
Seizures
Hypoglycemia
Hypophosphatemia
Hypoalbuminemia
Ascites
Cirrhosis
Pancreatitis
Encephalopathy
Hypokalemia
Respiratory alkalosis
Metabolic acidosis
Hypoalbuminemia
Hyperammonemia
GI bleeding
Aplastic anemia
| Stage I | Stage II | Stage III | Stage IV |
|---|---|---|---|
| Symptoms | |||
| Periods of lethargy, euphoria; reversal of day-night sleeping; may be alert | Drowsiness, inappropriate behavior, agitation, wide mood swings, disorientation | Stupor but arousable, confused, incoherent speech | Coma IVa responds to noxious stimuli IVb no response |
| Signs | |||
| Trouble drawing figures, performing mental tasks | Asterixis, fetor hepaticus, incontinence | Asterixis, hyperreflexia, extensor reflexes, rigidity | Areflexia, no asterixis, flaccidity |
| EEG (Electroencephalogram) | |||
| Normal | Generalized slowing, θ waves | Markedly abnormal, triphasic waves | Markedly abnormal bilateral slowing, δ waves, electric-cortical silence |
In children, hepatic encephalopathy is not an absolute hallmark of hepatic failure and may be difficult to diagnose. It does not exhibit the same clear gradation in severity as it does in adults.
In infants, no formal staging exists. The only findings for hepatic encephalopathy in infants may be irritability, poor feeding, and/or a change in sleep rhythm.