Intensive care of the patient with cirrhosis

Abstract

Acute deterioration of patients with cirrhosis manifests as multiple organ failure requiring admission to an intensive care unit. Precipitating events may be viral hepatitis, typically in Asia, and drug or alcoholic hepatitis and variceal hemorrhage in the West. Patients with cirrhosis in the intensive care unit have a high mortality, and each admission is associated with a mean charge of US $116,200. Prognosis is determined by the number of organs failing (sequential organ failure assessment [SOFA] score), the presence of infection, and the degree of liver dysfunction (Child‐Turcotte‐Pugh or Model for End‐Stage Liver Disease scores). The most common organ failing is the kidney; sepsis is associated with further deterioration in liver function by compromise of the microcirculation. Care of these critically ill patients with impending multiple organ failure requires a team approach with expertise in both hepatology and critical care. Treatment is aimed at preventing further deterioration in liver function, reversing precipitating factors, and supporting failing organs. Liver transplantation is required in selected patients to improve survival and quality of life. Treatment is futile in some patients, but it is difficult to identify these patients a priori. Artificial and bioartificial liver support systems have thus far not demonstrated significant survival benefit in these patients. (HEPATOLOGY 2011)

Hepatitis E and Acute-on-Chronic Liver Failure

“…36 The goals of treatment are to prevent further deterioration in liver function, reverse precipitating factors, and support failing organs. Liver transplantation is required in selected patients to improve survival and quality of life.…”

“…Liver transplantation is required in selected patients to improve survival and quality of life. 36 Endotracheal intubation for airway control is mandatory in patients with a Glasgow coma scale score of <8 and/or in the presence of active upper gastrointestinal bleeding. 36 Management of respiratory failure and acute lung injury mandates the use of lung protective ventilation strategies; low tidal volume $6 mL/kg of predicted body weight, positive end-expiratory pressure to maintain satisfactory oxygenation, and plateau pressures <30 cm/H 2 O to prevent further lung injury.…”

“…Sedatives delay extubation and prolong altered consciousness, hence they should be avoided. 36 All patients, whether ventilated or not, should undergo early mobilization and early initiation of physical therapy to prevent weakness associated with immobility and critical illness.…”

“…Vasopressin (or terlipressin) is norepinephrine-sparing in sepsis and appears to have a similar effect in patients with cirrhosis. 36 The current recommendation for treatment of hepatorenal syndrome includes volume expansion with albumin (1 g/kg maximum 100 g/day initial dose then followed by20-40 g/day) and vasoconstrictors with the goal of treatment to decrease the serum creatinine to <1.2 mg/dL. The choice of vasoconstrictor depends on availability.…”

“…Alternative regimens include norepinephrine at a dose of 0.5-3 mg/h as a continuous infusion; midodrine at a dose of 7.5-12 mg orally three times daily with octreotide at a dose of 100-200 mg subcutaneously three times daily. 36,37 Elevated intra abdominal pressure due to tense ascites may also result in the abdominal compartment syndrome which leads to renal, cardiovascular, and respiratory dysfunction. 36,38 Large-volume paracentesis with concomitant albumin replacement at 6-8 g albumin per liter of ascites removed may be essential to reduce intra abdominal pressure.…”