Guidelines Offer Management Strategies for Liver Failure in the ICU: Presented at SCCM

By Nancy Melville

ORLANDO, Fla -- February 21, 2020 -- New guidelines provide recommendations for the management of acute and acute-on-chronic liver failure in the intensive care unit (ICU), according to a study presented here at the 2020 Annual Meeting of the Society of Critical Care Medicine (SCCM).

The guidelines from SCCM address various unique clinical challenges and the potentially high mortality risk that such cases present.

“Often, clinical care must be adapted to individual clinical circumstances and patient/family preferences,” reported Rahul Nanchal, MD, Medical College of Wisconsin, Milwaukee, Wisconsin; Ram Subramanian, MD, Emory University Hospital, Atlanta, Georgia; and colleagues. “These guidelines are meant to supplement and not replace an individual clinician’s cognitive decision-making. The primary goal of these guidelines is to aid best practice and not represent standard of care.”

The guidelines, developed from an evidence review by a multidisciplinary international committee of experts, include 29 evidence-based recommendations in 5 key subgroups: cardiovascular, haematology, pulmonary, renal, and endocrine/nutrition.

They address 2 forms of hepatic failure, ie, acute liver failure (ALF), which is life-threatening and associated with rapid loss of liver function over days or weeks in a previously healthy person; and acute-on-chronic liver failure (ACLF), which can occur among patients with preexisting chronic liver disease.

Six of the recommendations were considered strong, 19 were conditional, and 4 were best-practice statements. In 2 cases, no recommendation was issued because of insufficient evidence.

Strong recommendations include the following.

(1) In critically ill patients with ALF or ACLF, hydroxyethyl starch is not recommended for initial fluid resuscitation, with evidence suggesting no benefit of the starch over crystalloids and that starches may exacerbate coagulopathy in liver failure.

(2) Norepinephrine is recommended as a first-line vasopressor in patients with ALF or ACLF who continue to have hypotension despite fluid resuscitation or those with profound hypotension and tissue hypoperfusion even with ongoing fluid resuscitation. Studies have suggested superiority of norepinephrine over dopamine in reversing hypotension, being associated with lower mortality and decreased risk of arrhythmias.

(3) Viscoelastic testing (thromboelastography/rotational thromboelastometry [TEG/ROTEM]) is recommended over measuring international normalised ratio, platelet, and fibrinogen, in critically ill patients with ALF or ACLF undergoing procedures. This is in part because TEG/ROTEM determines global coagulation status.

(4) Eltrombopag treatment is not recommended in ACLF patients with thrombocytopenia before surgery/invasive procedures because it is associated with thrombotic events of the portal venous system.

(5) Vasopressors are recommended in critically ill patients with ACLF who develop hepatorenal syndrome, which can have a very poor prognosis.

(6) A conventional target serum blood glucose level of 110 to 180 mg/dL is recommended for patients with ALF and ACLF and hyperglycaemia, because evidence suggests that very tight glucose control may increase the risk of hypoglycaemia in such cases.

The full list of recommendations, along with rationales, is published online in Critical Care Medicine (Nanchal R et al. 2020;48:415-419. doi: 10.1097/CCM.0000000000004193).

[Presentation title: Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Cardiovascular, Endocrine, Hematologic, Pulmonary, and Renal Considerations]

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