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Guidelines for the initial management of paediatric liver disease

Alastair Baker
Investigation and treatment of liver disease with acute onset –
Local hospital protocol

 Defined as EITHER sudden onset of jaundice with evidence of liver aetiology OR incidental discovery of raised transaminases in association with symptoms suggesting acute onset  Age of onset >3 months  Investigate and treat as neonatal jaundice before 3 months  Acute Liver Failure (ALF): INR>2.0 due to liver dysfunction of less than 8 weeks duration without encephalopathy or >1.5 with encephalopathy requires transfer to Transplant Centre.
Early Measures
 Ensure given vitamin K parenterally at least once and regularly by mouth  Ensure not hypoglycaemic with BM stix before feeds >4.0 for at least 24 hours – give IV dextrose to ensure blood glucose >4.0 mmol/l.  Ask and record colour of urine and stool.  Take history and perform examination especially for features of chronicity of liver disease.  Bloods – HAV IgM, FBC, INR, DIC screen, renal, bone liver profiles, total and conjugated bilirubin levels, HBV SAg.  If INR>2 TREAT AS LIVER FAILURE – If INR raised liver failure may be  Contact SpR at Transplant Centre. Do not wait for results to make contact.  Preliminary investigations – blood and urine cultures, urine drug screen, plasma paracetomol level if any indication, Immunoglobulins, C3, C4, auto-antibodies, pANCA, copper, zinc, caerulopasmin, hepatitis C antibody, alpha-fetoprotein, liver ultrasound.  Liaise with SpR at Transplant Centre to arrange transfer according to urgency depending on above information. Investigations in Acute Liver Failure
Core investigations – prior to all investigation protocols FBC, retics, film ? haemolysis/cytopenia If prolonged treat with vit K 1mg IV and repeat in 6-8 hr. Blood Group to be known -1-antitrypsin phenotype (from PIZZ – deficiency parents if transfused) Renal, lipid, bone, and liver profiles, Profile of liver dysfunction split bilirubin, creatine kinase Urine C&S Ethics committee consent obtained for all patients – inform parents as courtesy Liver ultrasound Evidence and nature of liver disease Glucose/BM stick 4 hourly SAVE INITIAL URINE
Drugs especially paracetomol toxicology screen
Hepatitis A IgM, B IgM anticore, anti Hep C Hepatitis viruses A, B, C (URGENT to Institute antibodies, Hep C RNA of Liver Studies) Fibrinogen (coagulation form) Auto-antibodies, immunoglobulins, Auto-immune hepatitis Pancreatitis, myositis Urea cycle disorder Leptospirosis CMV, EBV, HSV, V-Z adenovirus, Parvovirus (PCR may be necessary) HHV6. CXR, ECG (ECHO if indicated) Low serum levels noted at presentation Blood gases lactate, pyruvate, PYRUVATE discuss with biochemist first
Management of ALF while waiting for transfer
 Nurse child with head elevated at 20o and no neck flexion (to decrease I.C.P. and minimize cerebral irritability)  DO NOT SEDATE unless already ventilated - this may precipitate respiratory failure.  Maintain oxygenation with facial oxygen, unless this increases the  Maintain blood sugar between 4 - 9 mmol/l using minimal fluid volume (40 - 60 ml/kg/day crystalloid) with high dextrose concentrations e.g. 10% - 20% add K as necessary.  Strict monitoring of urinary output and fluid balance. Catheterise if necessary. Check urinary electrolytes, urea creatinine and osmolarity.  Frequent neuro-obs (hourly to 4 hourly as clinically indicated)  Give one dose of Vit K (1-5 mg IV) to attempt correction of prolonged clotting time. If frank bleeding (GIT or other) occurs consider prudent use of FFP at 10 ml/kg IV OR cryoprecipitate at 5 ml/kg IV only for bleeding or insertion of monitoring devices. (FFP will mask prognostic value of INR). Factor VIIa may be used for persistent bleeding.  CMV negative irradiated blood required for all children <1 year and agreed with haematology.  Prophylactic Ranitidine 3 mg/kg/dose tds (max dose 50mg) IV plus oral antacid to prevent gastric/duodenal ulceration.  IV Cefuroxime 20 mg/kg three times daily (Max dose 1.5 gram three times daily) or Tazocin 90mg/kg/dose tds (mximun single dsoe 4.5g) x 7 days.  Antifungal- Fluconazole - 6mg/kg/day once daily (max 200mg/day once daily) x7-14 days  Infants <2 should receive acyclovir IV 20mg/Kg 8 hrly for 14 days or until herpes infection is excluded.  Patients with renal dysfunction on high WBC also require liposomal Amphotericin IV.  Lactulose to produce 2 - 4 soft stools per day if patient conscious - omit if  Stop oral protein initially. Gradually reintroduce 0.5 g-1g/kg/24 hours. Fluid Balance
 Strict fluid balance is essential in liver failure  Daily weights are required if the child can be moved.  Aim for urine output not less than 0.5 ml/kg/hr  Volume given calculated from formula (If child is not dehydrated and losses are not abnormal). Daily Maintenance Fluid = approx 2/3 maintenance 2/3x(100ml/Kg body weight for the first 10 Kg+50ml/Kg for the next 10Kg+10ml/Kg for each Dextrose >10% or higher if hypoglycaemic (BM<4.0) 1.0 - 3.5 mmol/kg/day NIL while anuric
Paracetamol Overdose Treatment Protocol
If a Paracetamol overdose is suspected or known, the child must be treated
immediately with N-acetylcysteine, at the local hospital whatever the time
between the alleged overdose and the visit to the hospital. The ‘High Risk
Treatment Line' is used in all cases once a level is known. The N-acetylcysteine
should be continued until the INR is normal (<1.2). Indication for treatment after
known time since ingestion by plasma level corresponding to the High Risk
Treatment Line is shown below.

 Liver function tests, paracetamol level, INR, blood sugar, renal function tests and blood gases including lactate. Blood sugar must be closely monitored - (hourly BM stix).  Urine drug screen should be performed as soon as possible  INR, blood sugar, renal function and blood gases must be repeated at least twice a day and, if abnormal, three times a day. Start immediately broad spectrum antibiotics if INR abnormal and in the presence of abnormal renal function, liposomal Amphotericin i.v.  Hypoglycaemia has to be avoided and the child should be maintained on 10% dextrose. Higher concentrations of dextrose may be needed.  The most important prognostic parameter is acidosis on day 2. If, despite N-acetylcysteine treatment and good rehydration, the child becomes acidotic, the prognosis is poor. Acidosis is the best prognostic factor independent from all other factors. Even in the presence of a very prolonged INR, a patient who is not acidotic will have 80% chances of surviving. If the pH is <7.25, there is a 95% mortality, therefore the child should be emergency listed for transplantation.  Other factors predicting a poor outcome are the development of grade III hepatic encephalopathy with oliguric renal failure (which usually occurs three to four days after ingestion), and/or a prothrombin time of >100 seconds, and raised plasma lactate.