What management strategies should I consider for a patient with acute liver failure due to paracetamol overdose?

Management of acute liver failure (ALF) caused by paracetamol overdose requires immediate and comprehensive intervention to prevent progression and improve outcomes. Initial management includes prompt assessment of the overdose timing and quantity, followed by administration of intravenous N-acetylcysteine (NAC) as the antidote, which is critical to replenish glutathione and detoxify the toxic metabolite of paracetamol ¹. Supportive care in an intensive care setting is essential, focusing on monitoring and managing complications such as coagulopathy, encephalopathy, metabolic disturbances, and multi-organ failure (Saner et al., 2024). Early involvement of a specialist liver unit is recommended for consideration of liver transplantation in cases where there is evidence of poor prognosis despite maximal medical therapy ¹.

Specific strategies include correction of coagulopathy with vitamin K and blood products as needed, careful fluid and electrolyte management, and prevention of cerebral oedema through intracranial pressure monitoring and measures to reduce raised intracranial pressure (Saner et al., 2024). Infection surveillance and prophylaxis are important due to immunosuppression in ALF ¹. Advanced intensive care techniques such as extracorporeal liver support systems may be considered as a bridge to transplantation or recovery, although their routine use remains under evaluation (Saner et al., 2024). Close monitoring of renal function is also vital, as acute kidney injury frequently complicates paracetamol-induced ALF ¹.

In summary, the management strategy integrates early antidote therapy with NAC, intensive supportive care in a specialist setting, correction of metabolic and coagulation abnormalities, prevention of complications, and timely evaluation for liver transplantation, supported by advanced critical care interventions as indicated ¹; (Saner et al., 2024).