Acute liver failure (ALF), decompensated cirrhosis, and acute-on-chronic liver failure (ACLF) comprise some of the most challenging diseases states that intensivists try to stabilize and treat. These patients often decline in subtle ways at first and then will deteriorate rapidly into fulminant multi-system organ failure. For a primer on decompensated cirrhosis or ACLF, take a look at one of our previous posts. Luckily, the Society of Critical Care Medicine has published a concise set of recommendations and guidelines to standardize care across the spectrum of these diseases. While these guidelines are by no means comprehensive, it is certainly a starting point when it comes to standardization of practice. In addition to recommendations about other routine ICU practices, we chose to highlight some of the more resuscitation-forward recommendations.
Key SCCM Recommendations:
Diagnosis of Hypotension and Shock:
- There was no evidence to suggest that ACLF or ALF should get a lower MAP target than any other disease state. As such, for both ALF and ACLF, a MAP of >65 should remain a resuscitation target.
- Similar to other disease states in the ICU, refractory hypotension and shock in ALF and ACLF deserve close monitoring with an arterial line.
- The guidelines found pretty strong evidence to argue that hydroxyethyl starch is probably a bad idea when it comes to resuscitating hypovolemia or hypotension in these patients. Likewise, they recommended against using gelatin solutions.
- For liver patients that require fluid resuscitation AND have known albumin of <3mg/dL, albumin-based resuscitation (either with 5% or 25%) is recommended over isotonic crystalloid.
Vasopressors and Shock:
- ALF and ACLF shock states tend to be more distributive in nature, and ACLF is often complicated by sepsis and septic shock. These guidelines highlight norepinephrine as the first choice of pressor.
- Low dose, non-titratable vasopressin infusion should be added when the shock is refractory to fluid resuscitation and norepinephrine infusion.
- Stress dose glucocorticoids should be added in ALF or ACLF in refractory shock or for those needing higher doses (or multiple) vasopressors.
Clots, Coagulopathy and Bleeding:
- The transfusion target for hemoglobin remains at 7 mg/dL in ALF and ACLF.
- Patients with ACLF should receive chemical prophylaxis for venous thromboembolism.
- Instead of screening and/or transfusing to meet INR, platelet, or fibrinogen thresholds, SCCM recommends using viscoelastic testing (ROTEM or TEG) in critically ill patients who need a procedure.
Hypoxia and Acute Respiratory Failure:
- Unless acute cardiopulmonary edema or hypercarbia is clearly evident, supportive care with high flow nasal cannula is preferred over non-invasive positive pressure ventilation.
- Consider pleurodesis or pleurex catheters for patients with refractory hepatohydrothorax if transjugular intrahepatic portosystemic shunt (TIPS) is not an option.
Invasive Mechanical Ventilation:
- ACLF and ALF can precipitate ARDS. Not surprisingly, SCCM recommends using standard ARDSnet vent settings, airing on the side of higher PEEP and lower tidal volumes (6-8 ml/kg of ideal body weight).
- For escalating renal failure, early renal replacement therapy may improve outcomes.
- For patients satisfying hepato-renal syndrome, early vasopressor therapy may improve outcomes.
Cum Grano Salis
As with all guidelines, it’s important to keep these recommendations in the context of what they are: largely consensus guidelines from an expert panel evaluating incomplete evidence. There are 5 out of a total of 31 recommendations that the guidelines cite as being a “strong” recommendation with at least moderate quality of evidence to back it. These top 5 are:
- Don’t use hydroxyethyl starch to resuscitate patients.
- Target a glucose level between 110-180 mg/dL (not mentioned above given that’s common practice for nearly every ICU patient).
- Use norepinephrine as a first-line vasopressor.
- Use TEG/ ROTEM for pre-procedure optimization and not INR, PLT, or fibrinogen cut-offs.
- Use vasopressors in patients with hepatorenal syndrome.
Some centers may or may not have access to various modalities of support when it comes to some of these recommendations. IHD vs CRRT is a big limitation in community centers, as is the ability to perform viscoelastic assays. The decision to adopt/ implement these practices (and also criteria for transfer to a liver center) should always be discussed ahead of time within your practice group and regional referral infrastructure.
ALF and ACLF are challenging entities, but they continue to be common causes of ICU admission, with sometimes prolonged stay. ALF and ACLF often have multi-system dysfunction, but often patients will respond to common critical care support modalities. The SCCM guidelines provide some insight into some key day-to-day critical care interventions that seem to work.
Further Reading and Listening:
There is a fantastic set of podcasts from Critical Matters that covers this content and document as well. The lead author, Dr. Nanchal, is interviewed during this piece and gives a great insight into how these recommendations were formed.
- Nanchal et al. Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Cardiovascular, Endocrine, Hematologic, Pulmonary and Renal Considerations. Critical Care Medicine: March 2020 – Volume 48 – Issue 3 – p e173-e191 doi: 10.1097/CCM.0000000000004192
- Nanchal, R., Subramanian, R., Karvellas, C. J., Hollenberg, S. M., Peppard, W. J., Singbartl, K., … & Alhazzani, W. (2020). Guidelines for the management of adult acute and acute-on-chronic liver failure in the ICU: cardiovascular, endocrine, hematologic, pulmonary, and renal considerations. Critical care medicine, 48(3), e173-e191.
- Haase, N., Perner, A., Hennings, L. I., Siegemund, M., Lauridsen, B., Wetterslev, M., & Wetterslev, J. (2013). Hydroxyethyl starch 130/0.38-0.45 versus crystalloid or albumin in patients with sepsis: a systematic review with meta-analysis and trial sequential analysis. Bmj, 346.
- Avni, T., Lador, A., Lev, S., Leibovici, L., Paul, M., & Grossman, A. (2015). Vasopressors for the treatment of septic shock: systematic review and meta-analysis. PloS one, 10(8), e0129305.
- De Pietri, L., Bianchini, M., Montalti, R., De Maria, N., Di Maira, T., Begliomini, B., … & Villa, E. (2016). Thrombelastography‐guided blood product use before invasive procedures in cirrhosis with severe coagulopathy: a randomized, controlled trial. Hepatology, 63(2), 566-573.
- Wu, V. C., Ko, W. J., Chang, H. W., Chen, Y. S., Chen, Y. W., Chen, Y. M., … & Wu, K. D. (2007). Early renal replacement therapy in patients with postoperative acute liver failure associated with acute renal failure: effect on postoperative outcomes. Journal of the American College of Surgeons, 205(2), 266-276.