Management of Decompensated Cirrhosis in the Surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

Abstract

Management of decompensated cirrhosis (DC) can be challenging for the surgical intensivist. Management of DC is often complicated by ascites, coagulopathy, hepatic encephalopathy, gastrointestinal bleeding, hepatorenal syndrome, and difficulty assessing volume status. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews practical clinical questions about the critical care management of patients with DC to facilitate best practices by the bedside provider.

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

“…Central venous pressure, as a static parameter, is not a good indicator of actual blood volume, especially in the presence of ascites, diastolic dysfunction, and hypoalbuminemia [ 11 , 83 ]. Pulmonary artery catheter insertion is the gold standard for the measurement of preload, afterload, and cardiac output; however, it is an invasive technique associated with a high rate of serious adverse effects and is rarely used in the operating room.…”

“…Mean arterial pressure (MAP) can be monitored using both an intra-arterial catheter and a non-invasive monitor. A MAP target of 60–65 mmHg in ACLD patients grants organ perfusion [ 11 ]. Intra-arterial catheters can be used to quantify pulse pressure variation (PPV) or stroke volume variation (SSV), which are dynamic preload parameters based on the heart-lung interaction, widely used in surgical and critical patients.…”

“…For this reason, the fluid replacement must be goal-directed, according to the monitoring techniques mentioned previously. If the cardiovascular assessment indicates fluid-responsive hypovolemia, balanced solutions should be used, such as Plasmalyte, with a lower content of sodium and chloride and less risk to cause kidney failure than normal saline [ 11 ]. Hydroxyethyl starch should not be used due to its potential nephrotoxicity.…”

“…After a negative fluid challenge that leads to a worsening of arterial pressure or cardiac output, vasoactive drug therapy represents the starting point of the treatment. The vasoactive drug of choice during surgery in ACLD patients is norepinephrine [ 11 , 85 ]. Patients in chronic treatment with beta-blockers have an impaired cardiac response under stress conditions, so in order to avoid hypoperfusion, early use of norepinephrine is mandatory [ 79 ].…”

“…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 ].…”