急性肝不全 — 管理パス

パス全体像

1. 【判断】King's College criteria
   Etiology? Do King's College transplant criteria apply?（ALF = hepatic encephalopathy + coagulopathy (INR ≥1.5) within 26 weeks in someone without chronic liver disease. Etiologies: acetaminophen, viral hepatitis (HBV important in some regions), drugs, autoimmune, Wilson's, toxic mushrooms, etc. King's College criteria (predict poor prognosis/need for transplant) — acetaminophen: pH <7.30 (after resuscitation), or all of INR >6.5 + Cr >300 µmol/L + grade III–IV encephalopathy; non-acetaminophen: INR >6.5 alone, or any three of (age <10/>40, non-A non-B hepatitis/drug/Wilson etiology, jaundice-to-encephalopathy >7 days, INR >3.5, bilirubin >300 µmol/L).）
   • Meets King's College criteria / severe → Criteria met → early transfer to transplant center
   • Criteria not met / early → Early · support + NAC
2. 【終点】Early · support + NAC
   ICU monitoring, aggressive support — give N-acetylcysteine (NAC)の場合acetaminophen cannot be excluded (also beneficial earlyでnon-acetaminophen ALF); monitor neuro/coagulation/glucose/electrolytes/blood gas; manage hypoglycemia, cerebral edema, 感染 (low thresholdに対し抗菌薬); do not give prophylactic FFP (unless active 出血/before a procedure,・it confounds INR monitoring); reassess serially, transferに対し移植 once criteria are met.
3. 【終点】Criteria met → early transfer to transplant center
   King's College criteria met / 重症 (poor 予後): transfer earlyへa liver 移植 center (time-critical). Continue NAC; intensive ICU support: cerebral 浮腫/raised ICP (grade III–IV — head elevation, hypertonic saline/mannitol, avoid hypercapnia), frequent 血糖 checksへprevent hypoglycemia, AKI/renal replacement, broad-spectrum antimicrobials/antifungals (low threshold), correct 電解質/metabolic derangements, circulatory support; transfuse FFPに対しcoagulopathy only 〜あり active 出血/before a procedure. Etiology-specific treatment (antiviralsに対しHBV, penicillin/silibininに対しtoxic mushrooms, etc.).