Management of Sepsis in Patients With Cirrhosis: Current Evidence and Practical Approach

Abstract

Sepsis in patients with cirrhosis is associated with high mortality. An impaired immune response accounts for the increased infection risk observed in these patients. Hemodynamic and systemic changes suggestive of sepsis may be observed in patients with cirrhosis in the absence of infection; therefore, diagnosis and treatment of sepsis may be delayed. The optimal management of the critically ill patient with sepsis and cirrhosis has not been well established and is generally extrapolated from consensus guidelines and expert recommendations made for management of patients without cirrhosis with sepsis. Despite the lack of strong evidence, we propose a contemporary pragmatic approach to sepsis management in patients with cirrhosis, including the choice of fluids, vasopressors, and antibiotics.

Update on diagnosis and management of sepsis in cirrhosis: Current advances

“…Since protective ventilation (low tidal volumes of 6 mL/kg of ideal body weight and plateau pressures < 30 cm H 2 O) improves survival in general patients with adult respiratory distress syndrome, patients with cirrhosis who require mechanical ventilation should also be treated on the same lines. However, the sedation in such circumstances must ideally be with drugs with short half-lives such as propofol and remifentanil with avoidance of benzodiazepines[ 73 - 75 ]. In patients with cirrhosis, profound distributive shock leads to the development of refractoriness (a state of ”vasoplegia”) to inotrope, and pressor support is higher than that seen in non-liver patients with septic shock due to increased sympathetic drive, use of beta-blockers, and more severe relative adrenal insufficiency.…”

“… The proposed treatment algorithm for sepsis in cirrhosis[ 66 , 68 , 70 - 72 , 75 ]. BCAA: Branched-chain amino acids; FMT: Faecal microbiota transplantation; G-CSF: Granulocyte-colony stimulating factor; GM: Granulocyte-macrophage; ICU: Intensive care unit; IMRT: Intestinal microbiota re-instituition therapy; IV: Intravenous; LOLA: L-ornitine L-aspartate; LPS: Lipopolysaccharide; MDR: Multidrug resistant.…”

Prediction of 28‐day mortality in acute decompensation of cirrhosis through the presence of multidrug‐resistant infections at admission

“…Emerging data indicate a high prevalence of MDR infections in hospitalized cirrhotics with a high mortality . The European Association for the Study of the Liver (EASL) and American Association for the Study of Liver Diseases groups recommend empiric antibiotics of choice based on the local epidemiology, which may not be applicable to other countries. Therefore, we aimed to study the epidemiology of bacterial infections (including MDR) at admission among Indian cohort of cirrhotics with AD and evaluate their impact on the clinical outcomes.…”

The protective rather than prothrombotic fibrinogen in COVID‐19 and other inflammatory states

“…This is clearly evidenced in sepsis being one of the most common causes of death in patients with liver cirrhosis. 4 The liver, in its anti-infective role, releases several acute phase reactants including fibrinogen, ferritin, C-reactive protein (CRP), and a plethora of cytokines. Several reports have confirmed marked elevation of these acute phase proteins in patients requiring hospitalization for COVID-19, suggesting the liver function is in overdrive.…”