Intensive care management of acute-on-chronic liver failure

Abstract

The syndrome of acute-on-chronic liver failure combines deterioration of liver function in a patient with chronic liver disease, with the development of extrahepatic organ failure and high short-term mortality. Its successful management demands a rapid and coherent response to the development of dysfunction and failure of multiple organ systems in an intensive care unit setting. This response recognises the features that distinguish it from other critical illness and addresses the complex interplay between the precipitating insult, the many organ systems involved and the disordered physiology of underlying chronic liver disease. An evidence base is building to support the approaches currently adopted and outcomes for patients with this condition are improving, but mortality remains unacceptably high. Herein, we review practical considerations in critical care management, as well as discussing key knowledge gaps and areas of controversy that require further focussed research.

Clinical Guideline on Perioperative Management of Patients with Advanced Chronic Liver Disease

“…As nutritional reserves have prognostic implications, nutrition and micronutrient supplementation must be started early after surgery ( Figure 3 ). In patients with esophageal varices undertaking extra abdominal surgeries, the insertion of a nasogastric tube for enteral feeding is associated with a low risk of bleeding, and it is not contraindicated [ 8 ]. Enteral nutrition (EN) is preferred rather than parenteral feeding as it reduces infectious complications by preserving the intestinal mucosal barrier and healthy microbiota.…”

“…In non-hospitalized obese patients, calorie needs should be adjusted according to the body mass index. In critically ill patients, an increase in protein intake of up to 2 g/kg is recommended [ 8 , 34 ]. There are no current recommendations for the routine use of specific enteral feed formulas or protein restriction, neither in the presence of HE [ 8 , 34 ].…”

“…In critically ill patients, an increase in protein intake of up to 2 g/kg is recommended [ 8 , 34 ]. There are no current recommendations for the routine use of specific enteral feed formulas or protein restriction, neither in the presence of HE [ 8 , 34 ]. Although it was proposed that branched-chain amino-acids could be beneficial in cirrhosis or HCC, their recommendation in these pathologies is contradictory and, currently, cannot be extended to this population [ 106 ].…”

“…Current recommendations are based on the European Association for the Study of the Liver (EASL) review for the assessment of non-hepatic surgery risk in cirrhotic patients [ 6 ] and the intensive care management of acute-on-chronic liver failure (ACLF) [ 8 ], the American Gastroenterology Association (AGA) clinical practice update about perioperative management in cirrhosis [ 9 , 10 ], and the American Association for the Surgery of Trauma (AAST) consensus document on the management of decompensated cirrhosis in the surgical intensive care unit [ 11 ].…”

New concepts and perspectives in decompensated cirrhosis

“…11 The final two chapters focus on the sickest patients with decompensated cirrhosis. The first of these is devoted to intensive care management of these patients with extremely high attendant risk of death 12 and the second to the issues surrounding liver transplantation of patients with ACLF and multiorgan failure. 13 This is particularly challenging because of the risk of potential futility and the lack of priority for patients at risk of imminent death, as current allocation systems fail to identify these high-risk patients.…”