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

Abstract

Objectives: To develop evidence-based recommendations for clinicians caring for adults with acute or acute on chronic liver failure in the ICU. Design: The guideline panel comprised 29 members with expertise in aspects of care of the critically ill patient with liver failure and/or methodology. The Society of Critical Care Medicine standard operating procedures manual and conflict-of-interest policy were followed throughout. Teleconferences and electronic-based discussion among the panel, as well as within subgroups, served as an integral part of the guideline development. Setting: The panel was divided into nine subgroups: cardiovascular, hematology, pulmonary, renal, endocrine and nutrition, gastrointestinal, infection, perioperative, and neurology. Interventions: We developed and selected population, intervention, comparison, and outcomes questions according to importance to patients and practicing clinicians. For each population, intervention, comparison, and outcomes question, we conducted a systematic review aiming to identify the best available evidence, statistically summarized the evidence whenever applicable, and assessed the quality of evidence 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. Measurements and Main Results: In this article, we report 29 recommendations (from 30 population, intervention, comparison, and outcomes questions) on the management acute or acute on chronic liver failure in the ICU, related to five groups (cardiovascular, hematology, pulmonary, renal, and endocrine). Overall, six were strong recommendations, 19 were conditional recommendations, four were best-practice statements, and in two instances, the panel did not issue a recommendation due to insufficient evidence. Conclusions: Multidisciplinary international experts were able to formulate evidence-based recommendations for the management acute or acute on chronic liver failure in the ICU, acknowledging that most recommendations were based on low-quality indirect evidence.

Clinical Considerations of Coagulopathy in Acute Liver Failure

“…51 Both the European Association for the Study of the Liver and the Society of Critical Care Medicine also recommend the use of thromboviscous technology, such as VET and TGA, to assess bleeding/thrombotic risks in critically ill patients with ALF. 2,42 Neither the latest study data nor the most professional society guidelines support relying on INR as the sole measure of coagulopathy in ALF. Future iterations and standardization of VET and TGA are likely to provide a more comprehensive representation of coagulopathy in ALF.…”

“…The process further exacerbates liver damage in ALF. 36 Overall, there is an overwhelming amount of evidence to suggest that the hemostasis in ALF is complex and rebalanced ( Table 2, 11,[39][40][41][42] TEG and ROTEM have long been utilized in liver transplantation as its use reduces blood and fluid infusion volume during surgery. [43][44][45] In ALF, the parameters reflecting primary and secondary hemostasis are typically normal on TEG.…”

Chinese expert consensus on diagnosis and treatment of coagulation dysfunction in COVID-19

“…If plasma is unavailable or less than 2000 ml, plasma adsorption, perfusion, hemofiltration and their combination therapy are recommended [48]. Viscoelastic tests are recommended to evaluate coagulation function and monitor anticoagulation therapy in critically ill patients with liver failure [49].…”

Serum Albumin Levels: Who Needs Them?

“…A guideline for the management of adult acute and acute-on-chronic liver failure in the ICU has a conditional recommendation based on low-quality evidence that suggests using albumin over other resuscitation fluids “especially when serum albumin is low,” with low defined as less than 3 mg/dL. 12 The 3-mg/dL target was based on the ALBIOS trial that involved patients being resuscitated for severe sepsis and septic shock, 9 not liver failure. No trial, including ALBIOS, has demonstrated a well-defined relationship between specific cutoff values for serum albumin levels and clinically important outcomes associated with exogenous albumin administration.…”