Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Cardiovascular, Endocrine, Hematologic, Pulmonary and Renal Considerations
Recommendations
1) We recommend against using hydroxyethyl starch for initial fluid resuscitation of patients with ALF or ACLF.
( Strong , Moderate )2) We suggest against using gelatin solutions for initial fluid resuscitation of patients with ALF or ACLF.
( Conditional , Low )3) We suggest using albumin for resuscitation of patients with ALF or ACLF over other fluids, especially when serum albumin is low (< 3 mg/dL).
( Conditional , Low )4) We suggest targeting a mean arterial pressure of 65 mm Hg in patients with ALF or ACLF, with concomitant assessment of perfusion.
( Conditional , Moderate )4) We suggest targeting a mean arterial pressure of 65 mm Hg in patients with ALF or ACLF, with concomitant assessment of perfusion.
( Conditional , Low )6) We suggest using invasive hemodynamic monitoring to guide therapy in patients with ALF or ACLF and clinically impaired perfusion.
( Conditional , Low )7) We recommend using norepinephrine as a first-line vasopressor in patients with ALF or ACLF who remain hypotensive despite fluid resuscitation, or those with profound hypotension and tissue hypoperfusion even if fluid resuscitation is ongoing.
( Strong , Moderate )8) We suggest adding low-dose vasopressin to norepinephrine in patients with ALF or ACLF who remain hypotensive despite fluid resuscitation to increase blood pressure.
( Conditional , Low )9) We suggest using viscoelastic testing (TEG/ROTEM) over measuring INR, platelet, and fibrinogen in critically ill patients with ALF or ACLF.
( Conditional , Low )10) We suggest using a transfusion threshold of 7 mg/dL, over other thresholds, for critically ill patients with ALF or ACLF.
( Conditional , Low )11) We suggest using LMWH or vitamin K antagonists, over conservative management, in patients with portal venous thrombosis or pulmonary embolus.
( Conditional , Very Low )12) We suggest using LMWH, over pneumatic compression stockings for VTE prophylaxis in hospitalized patients with ACLF.
( Conditional , Low )13) We recommend viscoelastic testing (TEG/ROTEM), over measuring INR, platelet, fibrinogen, in critically ill patients with ALF or ACLF undergoing procedures.
( Strong , Moderate )14) We recommend against using Eltrombopag in ACLF patients with thrombocytopenia prior to surgery/invasive procedures.
( Strong , Low )15) We suggest using a low tidal volume strategy over high tidal volume strategy in patients with ALF or ACLF and ARDS.
( Conditional , Low )16) We suggest against using high PEEP, over low PEEP, in patients with ALF or ACLF and ARDS.
( Conditional , Low )17) We suggest treating portopulmonary hypertension with agents approved for pulmonary arterial hypertension in patients with mean pulmonary artery pressure > 35 mm Hg.
( Conditional , Very Low )18) We recommend supportive care with supplemental oxygen in the treatment of hepatopulmonary syndrome, pending possible liver transplantation.
(, )19) We recommend placing chest tube with an attempt to pleurodesis for hepatic hydrothorax in patients in whom TIPS is not an option or as a palliative intent.
(, )20) We suggest using high-flow nasal cannula over noninvasive ventilation in hypoxic critically ill patients with ALF or ACLF.
( Conditional , Low )21) There is insufficient evidence to recommend either continuing or discontinuing RRT intraoperatively (during liver transplant surgery) in patients who were receiving RRT preoperatively.
(, )22) We suggest using RRT early in patients with ALF and AKI.
( Conditional , Very Low )23) We recommend using vasopressors, over not using vasopressors, in critically ill patients with ACLF who develop HRS.
( Strong , Moderate )24) There is insufficient evidence to recommend either using or not using TIPS in patients with cirrhosis and refractory ascites to prevent HRS.
(, )(N/A)
25) We recommend targeting a serum blood glucose of 110–180 mg/dL in patients with ALF or ACLF.
( Strong , Moderate )26) We suggest using stress-dose glucocorticoids in the treatment of septic shock in patients with ALF or ACLF.
( Conditional , Low )27) We suggest against using a low protein goal in patients with ALF or ACLF, but rather targeting protein goals comparable to critically ill patients without liver failure (1.2–2.0 g protein/kg dry or ideal body weight per day).
( Conditional , Very Low )28) We suggest not using branch chain amino acids in critically ill patients hospitalized with ALF or ACLF who are tolerating enteral medications.
( Conditional , Very Low )29) We suggest enteral nutrition over parenteral nutrition in critically ill patients hospitalized with ALF or ACLF without contraindication for enteral feeding.
( Conditional , Low )30) We recommend screening patients with ALF or ACLF for drug-induced causes of liver failure. Drug that are proven or highly suspected to be the cause of ALF or ACLF should be discontinued.
(, )31) In patients with ALF or ACLF, we recommend adjusting the doses of medications that undergo hepatic metabolism based on the patient’s residual hepatic function and using the best available literature. When available, a clinical pharmacist should be consulted.
(, )ACLF = acute on chronic liver failure, ALF = acute liver failure, ARDS = acute respiratory distress syndrome, HRS = hepatorenal syndrome, LMWH = low molecular weight heparin, PEEP = positive end-expiratory pressure RRT = renal replacement therapy, TEG/ROTEM = thromboelastography/rotational thromboelastometry, TIPS = transjugular intrahepatic portosystemic shunt.
Recommendation Grading
Overview
Title
Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Cardiovascular, Endocrine, Hematologic, Pulmonary and Renal Considerations
Authoring Organization
Society of Critical Care Medicine
Publication Month/Year
February 1, 2020
Last Updated Month/Year
February 5, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
The purpose of these guidelines was to develop evidence-based recommendations addressing common clinical questions surrounding the unique manifestations of liver failure in the critically ill patient.
Target Patient Population
Critical ill patients with liver failure
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Emergency care, Hospital
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Management, Treatment
Diseases/Conditions (MeSH)
D017114 - Liver Failure, Acute, D017093 - Liver Failure, D008099 - Liver, D016638 - Critical Illness, D007362 - Intensive Care Units, D065290 - Acute-On-Chronic Liver Failure
Keywords
critical care, acute liver failure, critical illness, intensive care unit, liver failure, acute on chronic liver failure
Source Citation
Nanchal R, Subramanian R, Karvellas CJ, Hollenberg SM, Peppard WJ, Singbartl K, Truwit J, Al-Khafaji AH, Killian AJ, Alquraini M, Alshammari K, Alshamsi F, Belley-Cote E, Cartin-Ceba R, Dionne JC, Galusca DM, Huang DT, Hyzy RC, Junek M, Kandiah P, Kumar G, Morgan RL, Morris PE, Olson JC, Sieracki R, Steadman R, Taylor B, Alhazzani W. Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Cardiovascular, Endocrine, Hematologic, Pulmonary, and Renal Considerations. Crit Care Med. 2020 Mar;48(3):e173-e191. doi: 10.1097/CCM.0000000000004192. PMID: 32058387.
Supplemental Methodology Resources
Data Supplement, Data Supplement, Data Supplement, Data Supplement, Data Supplement, Data Supplement, Data Supplement