Patient's question:
Main symptoms: What medicine should children with liver failure take?Onset time: Test results:
Doctor's answer:
(1) Treatment of this condition requires enhanced basic supportive therapy. Comprehensive treatment measures should be adopted promptly to address the pre-coma stage of children, which may improve survival rates. The main measures should focus on: ① Reducing and clearing toxic substances; ② Preventing liver necrosis and promoting liver cell regeneration; ③ Supportive therapy and symptomatic treatment; ④ Prevention and treatment of complications; ⑤ Artificial liver support systems and liver transplantation.1. Basic supportive therapy
(1) Strict isolation: Children should be housed in isolated rooms, which should be disinfected and cared for by dedicated staff. Monitoring should include electroencephalography, intracranial pressure, and B-mode ultrasound.
(2) Dietary adjustment: For children with significant hepatitis-related gastrointestinal symptoms, protein intake (especially animal protein) should be restricted. In cases of pre-coma signs, strict fasting is required. The duration varies depending on the condition, typically lasting 3–5 days. Gradual refeeding should begin after improvement, starting with small amounts of carbohydrates. Protein intake should be gradually increased once the condition stabilizes. During fasting, daily caloric intake should not be less than 125.5–167.4 kJ/kg (30–40 kcal/kg). Adequate amounts of B vitamins, vitamin C, vitamin D, vitamin E, vitamin K, and adenosine triphosphate coenzyme A should be administered to supplement nutrition.
(3) Regulation of water and electrolyte balance: Low potassium, calcium, or magnesium levels should be corrected promptly. If blood sodium tests show no significant hyponatremia, excessive sodium supplementation should be avoided to prevent cerebral edema. During fasting, daily fluid intake should be strictly limited to no more than 1200 ml/m2. Glucose solutions should be infused to maintain nutrition and provide energy. For hypocalcemia, 10% calcium gluconate 5–10 ml should be administered intravenously daily. For every 200 ml of citrate blood transfused, an additional 1 g of calcium should be supplemented (calcium agents should not be added to the transfused blood). In cases of metabolic alkalosis, 25% arginine 20–60 ml should be administered intravenously. Hypokalemia is prone to causing metabolic alkalosis, which can induce or worsen hepatic encephalopathy. Potassium should be supplemented promptly if urine output is normal.
2. Promoting liver cell regeneration
(1) Glucagon-insulin therapy (G-I therapy): This has the effects of preventing liver cell necrosis, promoting liver cell regeneration, improving hyperammonemia, and adjusting amino acid metabolism. When used in appropriate proportions, they can have a synergistic effect. Dosage varies by age. Glucagon 0.2–0.8 mg and insulin 2–8 U (ratio of 1:8–1:10) should be added to 100–200 ml of 10% glucose solution and administered intravenously 1–2 times per day. The amount of glucose should be 4 g per unit of insulin. The course of treatment is typically 10–14 days.
(2) Human albumin or plasma: In liver failure, the synthesis of albumin by the liver is impaired. Infusion of human albumin helps liver cell regeneration and increases plasma colloid osmotic pressure, reducing ascites and cerebral edema. Albumin can also bind bilirubin, alleviating hyperbilirubinemia. Fresh plasma can supplement and, enhancing anti-infection capacity. Human albumin 0.5–1.0 g/kg and plasma 25–100 ml should be alternately administered daily or every other day.
(3) Hepatocyte growth factor (HGF): HGF 40–80 mg should be added to 100–200 ml of 10% glucose solution and administered intravenously once per day for a course of 1–2 months.
3. Immunomodulatory therapy: Thymosin can enhance disease resistance and reduce severe infections. It should be administered intramuscularly or intravenously at a dose of 10–40 mg per day or 40–80 mg twice or three times per week.
4. Prevention and treatment of complications
(1) Management of hepatic encephalopathy (see hepatic encephalopathy).
(2) Control of cerebral edema (see hepatic encephalopathy).
(3) Prevention and treatment of gastrointestinal bleeding:
① Supplement coagulation factors: Vitamin K1 10 mg should be administered 1–2 times per day. Infusion of thrombin complex factor is an effective measure for bleeding caused by reduced coagulation factors. The preparation is an extract of normal human plasma, containing concentrated factors II, VIII, IV, and X. It should be diluted with appropriate saline and administered intravenously. Due to its short half-life, it must be injected 6–8 times per day to control severe bleeding.
② Infusion of fresh blood or plasma: To supplement coagulation factors and lost blood volume.
③ Prevention and treatment of disseminated intravascular coagulation (DIC): If DIC is confirmed as the cause of bleeding, heparin should be administered at a dose of 1 mg (125 U)/kg 1–2 times per day until bleeding is controlled. Fresh whole blood should be infused daily during treatment, and coagulation time should be closely monitored to prevent excessive heparin-induced bleeding.
④ Histamine H2 receptor antagonists: Such as cimetidine (tagamet), 0.05–0.1 g twice or four times per day. This drug can also be used for prophylactic treatment, even if bleeding has not occurred. The use of such agents significantly reduces gastrointestinal bleeding, alleviating its severity. Ice saline with norepinephrine can also be administered via a gastric tube.
⑤ Hemostatic drugs: Neurophysin 5–10 U should be added to 50–100 ml of 10% glucose solution and administered intravenously. If necessary, it can be repeated every 3–4 hours. Omeprazole (losec) 5–20 mg should be administered intravenously once per day. Octreotide (sandostatin) 2 μg/kg should be added to 20 ml of 10% glucose solution and administered slowly intravenously. The maintenance dose is 10 μg/kg added to 500–1000 ml of 10% glucose solution and infused intravenously for 20 hours. Somatostatin (sandostatin) 5 μg/kg should be administered intravenously. The maintenance dose is 60 μg/kg added to 500–1000 ml of 10% glucose solution and infused intravenously for 12 hours. It can be used continuously for 24–72 hours. Terlipressin (trilipressin) 0.04 mg/kg should be administered slowly intravenously as an initial dose. The maintenance dose is 0.02–0.04 mg/kg administered intravenously every 4 hours for 24–36 hours until bleeding stops. Thrombin 50–200 U should be added to 50–100 ml of normal saline and administered orally every 2–8 hours. Yunnan Baiyao 0.1–0.5 g twice per day.
(4) Improving microcirculation: Anisodamine (654-2) has the effect of relaxing smooth muscles and dilating microvessels, significantly improving microcirculation and reducing liver cell damage. The dose is 0.5–1 mg/kg administered intravenously twice per day. It should be switched to oral administration once hepatic encephalopathy significantly improves and discontinued once liver function recovers. Chinese medicine injections such as Ligusticum chinense injection or Compound Salvia miltiorrhiza injection have the effects of promoting blood circulation, resolving stasis, and improving microcirculation. Ligusticum chinense 3–4 mg/kg should be administered intravenously twice per day, diluted with glucose solution. Compound Salvia miltiorrhiza 2–4 ml should be administered intravenously 1–2 times per day, diluted with glucose solution. Either can be chosen.
(5) Prevention and treatment of secondary infections: Children with liver failure are prone to secondary infections, often bacterial or fungal, which are usually hospital-acquired. In addition to strict isolation and room disinfection, early use of effective antibiotics should be considered. However, antibiotics that damage the liver and kidneys and glucocorticoids should be avoided. Penicillin-class antibiotics or those that inhibit gram-negative bacteria are commonly selected. Fungal infections should be treated by discontinuing broad-spectrum antibiotics.
(6) Prevention and treatment of hepatorenal syndrome (HRS): The main goal is to remove triggers such as hypokalemia, infection, and bleeding. Early treatment for HRS cannot be distinguished from pre-renal renal failure. Volume expansion therapy can be performed. If urine output reaches 20–30 ml/h or exceeds the pre-renal fluid intake, continue fluid infusion. Vasoactive drugs such as anisodamine (654-2) 0.05–1.00 mg/(kg·dose) and dopamine 0.05–1.00 mg/kg added to glucose solution for intravenous infusion can be used. Early diuretic therapy should be initiated. If tubular necrosis and renal failure occur, it is irreversible. Strict fluid restriction should be applied in cases of oliguria or anuria. Currently, there is no effective treatment for HRS.
5. Artificial liver and liver transplantation: Foreign studies have explored exchange transfusion, extracorporeal liver perfusion, artificial liver, and liver transplantation to improve survival rates in children with liver failure, gaining some experience. Liver transplantation is particularly effective in cases of pediatric liver failure caused by metabolic disorders. China is currently in the early stages of this treatment.
(2) Prognosis: This condition has a high mortality rate. Active treatment with comprehensive measures and prevention of complications can stabilize the condition. Children who survive have a slightly better prognosis than adults.