Managing Adult Acute and Acute-on-Chronic Liver Failure in the ICU
Xuan Han, MD, MS; Andrew M. Davis, MD, MPH; William F. Parker, MD, PhD
GUIDELINE TITLE Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Cardiovascular, Endocrine, Hematologic, Pulmonary, and Renal Considerations RELEASE DATE February 14, 2020 DEVELOPER AND FUNDING SOURCE Society of Critical Care Medicine (SCCM) TARGET POPULATION Critically ill adult patients with acute and acute-on-chronic liver failure MAJOR RECOMMENDATIONS • For patients who remain hypotensive despite fluid resuscitation, or those with profound hypotension and tissue hypoperfusion even with fluid resuscitation, norepinephrineis recommended first-linevasopressor (strong recommendation, moderate quality of evidence [QOE]). • In patients who develop hepatorenal syndrome, use of vasopressors (terlipressin, norepinephrine, or midodrine and octreotide) is recommended over not using them (strong recommendation, moderate QOE). • A target serum blood glucose of 110-180 mg/dL is recommended (strong recommendation, moderate QOE). • For patients undergoing procedures, viscoelastic testing (thromboelastography/rotational thromboelastometry TEG/ROTEM) is recommended over measuring international normalized ratio (INR), platelets, or fibrinogen (strong recommendation, moderate QOE). • In patients with thrombocytopenia, the use of eltrombopag prior to surgery/invasive procedures is not recommended (strong recommendation, low QOE). • The use of hydroxyethyl starch for initial fluid resuscitation is not recommended (strong recommendation,moderateQOE).