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To produce French guidelines on Management of Liver failure in general Intensive Care Unit (ICU). A consensus committee of 23 experts from the French Society of Anesthesiology and Critical Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Association for the Study of the Liver (Association française pour l'étude du foie, AFEF) was convened. A formal conflict-of-interest (COI) policy was developed at the start of the process and enforced throughout. The entire guideline process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Some recommendations were ungraded. Two fields were defined: acute liver failure (ALF) and cirrhotic patients in general ICU. The panel focused on three questions with respect to ALF: (1) Which etiological examinations should be performed to reduce morbidity and mortality? (2) Which specific treatments should be initiated rapidly to reduce morbidity and mortality? (3) Which symptomatic treatment should be initiated rapidly to reduce morbidity and mortality? Seven questions concerning cirrhotic patients were addressed: (1) Which criteria should be used to guide ICU admission of cirrhotic patients in order to improve their prognosis? (2) Which specific management of kidney injury should be implemented to reduce morbidity and mortality in cirrhotic ICU patients? (3) Which specific measures to manage sepsis in order to reduce morbidity and mortality in cirrhotic ICU patients? (4) In which circumstances, human serum albumin should be administered to reduce morbidity and mortality in cirrhotic ICU patients? (5) How should digestive haemorrhage be treated in order to reduce morbidity and mortality in cirrhotic ICU patients? (6) How should haemostasis be managed in order to reduce morbidity and mortality in cirrhotic ICU patients? And (7) When should advice be obtained from an expert centre in order to reduce morbidity and mortality in cirrhotic ICU patients? Population, intervention, comparison and outcome (PICO) issues were reviewed and updated as required, and evidence profiles were generated. An analysis of the literature and recommendations was then performed in accordance with the GRADE® methodology. The SFAR/AFEF Guidelines panel produced 18 statements on liver failure in general ICU. After two rounds of debate and various amendments, a strong agreement was reached on 100% of the recommendations: six had a high level of evidence (Grade 1 ±), seven had a low level of evidence (Grade 2 ±) and six were expert judgments. Finally, no recommendation was provided with respect to one question. Substantial agreement exists among experts regarding numerous strong recommendations on the optimum care of patients with liver failure in general ICU. [ABSTRACT FROM AUTHOR]

Résumé: De nombreuses substances, médicamenteuses ou non, peuvent être responsables d’hépatite aiguë. Cependant, l’origine toxique, hormis lorsqu’elle est évidente, est un diagnostic d’élimination. Les causes les plus fréquentes, notamment virales, doivent être recherchées en premier. Les hépatites médicamenteuses les plus fréquentes sont dues au paracétamol, aux antibiotiques, aux antiépileptiques et aux antituberculeux. L’évaluation de la gravité de l’atteinte hépatique est primordiale. Elle repose sur des critères cliniques et biologiques. L’insuffisance hépatique aiguë est définie par une diminution du facteur V respectivement supérieur à 50 % pour les formes modérées et inférieur à 50 % pour les formes sévères. L’examen neurologique doit être minutieux à la recherche de signes d’encéphalopathie pouvant être frustes initialement. Selon la classification française, l’hépatite fulminante est définie par l’apparition d’une encéphalopathie dans les deux premières semaines ou subfulminante lorsqu’il apparaît entre la deuxième et la 12e semaine après le début de l’ictère. L’administration, même tardive, de N-acétylcystéine dans des intoxications au paracétamol avec ou sans hépatite est fondamentale. De même, dans les insuffisances hépatiques aiguës non dues au paracétamol, mais présentant une encéphalopathie grade I ou II, l’administration de N-acétylcystéine a montré une amélioration de la survie sans transplantation. Le transfert du patient vers un centre spécialisé doit être discuté devant toute hépatite toxique et doit être systématique en cas d’insuffisance hépatique associée. Il ne faut pas attendre les critères de transplantation pour transférer le patient. [ABSTRACT FROM AUTHOR]