SCCM Guidelines for Acute and Acute-on-Chronic Liver Failure

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. 

Fluid Resuscitation:

• 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).

Kidney Injury:

• 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:

1. Don’t use hydroxyethyl starch to resuscitate patients.
2. Target a glucose level between 110-180 mg/dL (not mentioned above given that’s common practice for nearly every ICU patient).
3. Use norepinephrine as a first-line vasopressor.
4. Use TEG/ ROTEM for pre-procedure optimization and not INR, PLT, or fibrinogen cut-offs.
5. 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.