Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU Part 2

Publication Date: May 1, 2023
Last Updated: July 17, 2023

Neurology Section

We suggest not using invasive intracranial pressure (ICP) monitoring for critically ill ALF patients with advanced-grade encephalopathy. (C, VL)
620
We suggest, when available, using plasma exchange in critically ill ALF patients who develop hyperammonemia. (C, L)
620
We suggest using hypertonic saline in critically ill ALF patients who are at risk of developing intracranial hypertension. (C, L)
620
We suggest not routinely using induced moderate hypothermia (< 34°C) for critically ill ALF patients who are at risk of developing intracranial hypertension. (C, VL)
620
There was insufficient evidence to issue a recommendation on using lactulose, rifaximin, flumazenil, branch-chain amino acids, carnitine, zinc, probiotics, and L-ornithine L-aspartate (LOLA) in critically ill ALF patients with hyperammonemia. (U, U)
620
We suggest using nonabsorbable disaccharides in critically ill ACLF patients with overt hepatic encephalopathy. (C, L)
620
We suggest using enteral polyethylene glycol (PEG) as an alternative to lactulose in critically ill ACLF patients with overt hepatic encephalopathy. (C, L)
620
We suggest using oral rifaximin as adjunctive therapy in critically ill patients ACLF patients with overt hepatic encephalopathy. (C, L)
620
We suggest using LOLA in critically ill ACLF patients with overt hepatic encephalopathy. (C, VL)
620
We suggest not routinely using IV flumazenil, probiotics, zinc supplementation, glycerol phenylbutyrate (GPB), or acarbose as adjunctive therapies in critically ill ACLF patients with overt hepatic encephalopathy. (C, VL)
620

Infectious Diseases Section

We recommend using antibiotic prophylaxis in critically ill ACLF patients with any type of upper gastrointestinal bleeding (UGIB). (S, M)
620
We recommend using albumin in critically ill ACLF patients with SBP. (S, M)
620
We suggest using systemic antifungal prophylaxis in critically ill liver transplant recipients with risk factors for invasive fungal infections. (C, VL)
620
We suggest not using antifungal prophylaxis in critically ill liver transplant recipients at low risk for invasive fungal infections. (C, VL)
620
We suggest using appropriate antibiotics as soon as possible after recognition and within 1 hour of shock onset in critically ill ACLF patients with SBP and septic shock. (C, L)
620
We suggest not performing large volume paracentesis (LVP) in critically ill ACLF patients with SBP. (C, VL)
620
We suggest not using selective bowel decontamination (SBD) for critically ill liver transplant recipients. (C, L)
620
We recommend using broad spectrum antibiotic agents for the initial management of SBP in critically ill ACLF patients. (S, L)
620
We suggest not using midodrine or terlipressin empirically for critically ill ACLF patients with SBP. (C, VL)
620

Gastroenterology Section

We recommend performing esophagogastroduodenoscopy no later than 12 hours of presentation in critically ill ACLF patients with portal hypertensive bleeding (known or suspected). (U, U)
620
We recommend using proton pump inhibitors (PPIs) in critically ill ACLF patients with portal hypertensive bleeding. (S, L)
620
We recommend using octreotide or somatostatin analog (SSA) for the treatment of portal hypertensive bleeding in critically ill patients with ACLF. (S, M)
620
We suggest using transjugular intrahepatic portosystemic shunt (TIPS) for recurrent variceal bleeding after medical and endoscopic intervention over continued endoscopic therapy in critically ill ACLF patients. (C, L)
620
We recommend performing LVP with measurement of intra-abdominal pressure in critically ill ACLF patients with tense ascites and intra-abdominal hypertension or hemodynamic, renal or respiratory compromise. (U, U)
620

Peri-Transplant Section

We suggest using systemic corticosteroids for deceased liver graft donors. (C, VL)
620
We suggest either using goal-directed fluid management for the deceased organ donor or standard fluid management strategies. (C, VL)
620
There was insufficient evidence to issue a recommendation on using the donor risk index (DRI) in selection of liver allograft. (U, U)
620
We suggest using either extracorporeal liver support or standard medical therapy in critically ill ALF or ACLF patients. (C, VL)
620
There was insufficient evidence to issue a recommendation on peri-transplant fluid restriction accompanied by vasopressor use in liver transplant recipients. (U, U)
620
We suggest using balanced (or normochloremic) crystalloid solution over normal (hyperchloremic) saline for peri-transplant fluid replacement in liver transplant recipients. (C, L)
620
We suggest using albumin over crystalloid for intraoperative volume replacement during LT. (C, L)
620
There was insufficient evidence to issue a recommendation for the choice of intraoperative monitoring in LT recipients. (U, U)
620
There was insufficient evidence to issue recommendation on early extubation of liver transplant recipient. (U, U)
620

Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations

Authoring Organization

Publication Month/Year

May 1, 2023

Last Updated Month/Year

July 26, 2023

Document Type

Guideline

Country of Publication

US

Document Objectives

To develop evidence-based recommendations for clinicians caring for adults with acute liver failure (ALF) or acute on chronic liver failure (ACLF) in the ICU. In part 2 of this guideline, the panel was divided into four subgroups: neurology, peri-transplant, infectious diseases, and gastrointestinal groups. We developed and selected Population, Intervention, Comparison, and Outcomes (PICO) questions according to importance to patients and practicing clinicians. For each PICO question, we conducted a systematic review and meta-analysis where applicable. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence to decision framework to facilitate recommendations formulation as strong or conditional. We followed strict criteria to formulate best practice statements.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Emergency care, Hospital, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D017114 - Liver Failure, Acute, D017093 - Liver Failure, D065290 - Acute-On-Chronic Liver Failure

Keywords

acute liver failure, acute on chronic liver failure

Source Citation

Nanchal, Rahul MD, MS, FCCM (Co-Chair)1; Subramanian, Ram MD, FCCM (Co-Chair)2; Alhazzani, Waleed MBBS, MSc, FRCPC (Methods Chair, Vice Co-Chair)3; Dionne, Joanna C. MD, MS, BN3; Peppard, William J. PharmD, BCPS, FCCM4; Singbartl, Kai MD, MPH, EDIC, FCCM5; Truwit, Jonathon MD, MBA6; Al-Khafaji, Ali H. MD, MPH, FCCM7; Killian, Alley J. PharmD, BCPS2; Alquraini, Mustafa MBBS, SBEM, ABEM, MMed8; Alshammari, Khalil MBBS8; Alshamsi, Fayez MBBS8; Belley-Cote, Emilie MD3; Cartin-Ceba, Rodrigo MD, MS9; Hollenberg, Steven M. MD, FACC, FCCM, FAHA10; Galusca, Dragos M. MD, FASA, FCCP11; Huang, David T. MD, MPH, FCCM7; Hyzy, Robert C. MD, MCCM12; Junek, Mats BSc(H), MD3; Kandiah, Prem MD2; Kumar, Gagan MD, MA, MS13; Morgan, Rebecca L. PhD, MPH14; Morris, Peter E. MD15; Olson, Jody C. MD16; Sieracki, Rita MLS6; Steadman, Randolph MD17; Taylor, Beth DCN, RDN-AP, CNSC, FCCM18; Karvellas, Constantine J. MD, MS, FRCPC, FCCM (Vice Co-Chair)19. Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations. Critical Care Medicine 51(5):p 657-676, May 2023. | DOI: 10.1097/CCM.0000000000005824 

Supplemental Methodology Resources

Data Supplement