Review article: Practical considerations for fluid resuscitation in cirrhosis

Abstract

Background: Standard clinical methods of assessing volume and providing resuscitation are not always applicable to patients with advanced or decompensated cirrhosis. Despite this being well known from a clinical perspective, there remains relatively little evidence to guide clinicians though fluid management in patients with cirrhosis and, often, multi-organ system dysfunction. Aims: This review summarises the current understanding of the circulatory dysfunction in cirrhosis, modalities for assessing volume status, and considerations for fluid selection. It additionally provides a practical approach to fluid resuscitation. Methods: We review current literature on cirrhosis pathophysiology in steady-state and shock, clinical implications of fluid resuscitation, and strategies to assess intravascular volume. Literature reviewed here was identified by the authors through PubMed search and review of selected papers' references. Results: Clinical management of resuscitation in advanced cirrhosis remains relatively stagnant. Although several trials have attempted to establish the superior resuscitative fluid, the lack of improvement in hard clinical outcomes leaves clinicians without clear guidance. Conclusions: The absence of consistent evidence for fluid resuscitation in patients with cirrhosis limits our ability to produce a clearly evidence-based protocol for fluid resuscitation in cirrhosis. However, we propose a preliminary practical guide to managing fluid resuscitation in patients with decompensated cirrhosis. Further studies are needed to develop and validate volume assessment tools in the specific context of cirrhosis, while randomised clinical trials of protocolized resuscitation may improve care of this patient population. 1 | INTRODUC TI ON Cirrhosis carries high morbidity and mortality in the United States (US), representing approximately 3.8 per 1000 hospitalizations in the US per year and is the fourth leading cause of death among US adults ages 45-64 years old. 1,2 Patients with cirrhosis pose unique clinical challenges secondary to their disordered circulation and the multi-system consequences of advanced cirrhosis. As patients with cirrhosis are often volume overloaded overall and simultaneously have decreased effective arterial volume, their brittle hemodynamics make them prone to bleeding, renal injury, and cardiac overload. Standard clinical methods of assessing volume and providing | 1067 CLAUDEL et al.resuscitation are therefore not always applicable. The current literature lacks a comprehensive assessment of available evidence to provide goal-directed care to the patient with decompensated cirrhosis. This review will discuss assessment of volume status and the evidence behind choice of resuscitative therapies in cirrhosis, with an emphasis on critical illness.

Controversies Surrounding Albumin Use in Sepsis: Lessons from Cirrhosis

“…Patients with cirrhosis, especially those with decompensation or acute-on-chronic liver failure, often require intensive care and have high in-hospital mortality rates. AKI is a common complication typically managed with albumin [27,28]. The complexity of cirrhosis affects multiple organs, necessitating a comprehensive system-based approach to ICU care [29].…”