Liver Failure Management in the ICU: Clinical Practice Guidelines (2020)

Society of Critical Care Medicine

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

February 28, 2020

In February 2020, a panel from the Society of Critical Care Medicine published clinical practice management guidelines on adult acute and acute-on-chronic liver failure, as encountered in the intensive care unit (ICU).[1]

For patients with acute liver acute liver failure (ALF) or acute-on-chronic liver failure (ACLF), hydroxyethyl starch is not recommended for initial fluid resuscitation.

A mean arterial pressure (MAP) target of 65 mm Hg, with concomitant assessment of perfusion, is suggested for patients with ALF or ACLF.

In patients with ALF or ACLF whose hypotensive state is not normalized by fluid resuscitation, norepinephrine is recommended as a first-line vasopressor. This agent is also recommended in cases of ALF or ACLF marked by profound hypotension and tissue hypoperfusion, even if fluid resuscitation is ongoing.

In critically ill patients with ALF or ACLF who are undergoing invasive procedures, viscoelastic testing (thromboelastography/rotational thromboelastometry) is recommended over measurement of the international normalized ratio (INR), platelets, and fibrinogen, to assess bleeding risk.

Pending possible liver transplantation, it is recommended that the treatment of hepatopulmonary syndrome include supportive care employing supplemental oxygen.

When hepatorenal syndrome develops in critically ill patients with ACLF, vasopressor use is recommended.

In patients with ALF or ACLF, a serum blood glucose target of 110-180 mg/dL is recommended.

It is recommended that patients with ALF or ACLF be screened for drug-induced causes of liver failure, with discontinuation of drugs that are proven or highly suspected to be the source of ALF or ACLF.

With regard to medications that undergo hepatic metabolism, dosage adjustment is recommended in patients with ALF or ACLF, with such adjustments made according to a patient’s residual hepatic function and using the best available literature. Consultation should be carried out with a clinical pharmacist, if available.

For more information, please go to Acute Liver Failure.

For more Clinical Practice Guidelines, please go to Guidelines.

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