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1/ @sccm released a new table for the recent guidelines for the mgmt of acute (ALF) and acute-on-chronic liver failure (ACLF) in the ICU:
Summary table: https://bit.ly/374BEz0
Guidelines: https://bit.ly/343A1Q1
A summary of the summary below, the few strong recs are starred.
Summary table: https://bit.ly/374BEz0
Guidelines: https://bit.ly/343A1Q1
A summary of the summary below, the few strong recs are starred.
2/ Cardiac:
Use norepinephrine as first-line vasopressor, add vasopressin and stress-dose steroids for refractory shock
Target a MAP of 65 mm Hg
Use albumin for resuscitation, esp. when serum albumin <3 mg/dL
Use invasive hemodynamic monitoring to guide therapy
Use norepinephrine as first-line vasopressor, add vasopressin and stress-dose steroids for refractory shock Target a MAP of 65 mm HgUse albumin for resuscitation, esp. when serum albumin <3 mg/dLUse invasive hemodynamic monitoring to guide therapy
3/ Hematologic:
Use viscoelastic testing (TEG/ROTEM) over INR/platelet/fibrinogen in those undergoing procedures
Use transfusion threshold of 7 mg/dL
Use LMWH over SCDs for VTE prophylaxis in ACLF
Use LMWH or VKA over conservative mgmt for portal vein thrombosis or PE
Use viscoelastic testing (TEG/ROTEM) over INR/platelet/fibrinogen in those undergoing proceduresUse transfusion threshold of 7 mg/dLUse LMWH over SCDs for VTE prophylaxis in ACLFUse LMWH or VKA over conservative mgmt for portal vein thrombosis or PE
4/ Pulmonary:
Use low tidal volume strategy over high tidal volume strategy
Recommend against high PEEP (over low PEEP) in ARDS
Use high-flow oxygen over NIV for hypoxemia
Treat portopulmonary hypertension if mPAP>35 mm Hg
Use low tidal volume strategy over high tidal volume strategyRecommend against high PEEP (over low PEEP) in ARDSUse high-flow oxygen over NIV for hypoxemiaTreat portopulmonary hypertension if mPAP>35 mm Hg
5/ Pulmonary (continued):
Use oxygen for hepatopulmonary syndrome
Use chest tubes with attempt at pleurodesis for hepatic hydrothorax if TIPS not an option or for palliation
Use oxygen for hepatopulmonary syndromeUse chest tubes with attempt at pleurodesis for hepatic hydrothorax if TIPS not an option or for palliation
6/ Renal:
Use vasopressors in patients with ACLF who develop HRS
Use early RRT in patients with ALF and AKI
Endocrine:
Target serum blood glucose 110-180 mg/dL
Use vasopressors in patients with ACLF who develop HRSUse early RRT in patients with ALF and AKIEndocrine:
Target serum blood glucose 110-180 mg/dL
7/ GI
Use enteral nutrition rather than parenteral
Screen for drug-induced causes of liver failure, stop offending drugs
Adjust medications that undergo hepatic metabolism with the help of a clinical pharmacist
Use enteral nutrition rather than parenteralScreen for drug-induced causes of liver failure, stop offending drugsAdjust medications that undergo hepatic metabolism with the help of a clinical pharmacist
8/ Things to avoid:
Hydroxyethyl starch or gelatin solutions for fluid resuscitation
Eltrombopag for patients with ACLF and thrombocytopenia prior to procedures
A low protein goal
Hydroxyethyl starch or gelatin solutions for fluid resuscitationEltrombopag for patients with ACLF and thrombocytopenia prior to proceduresA low protein goal
9/ And finally, insufficient evidence for:
Intraoperative RRT for patients who were receiving preoperative RRT
TIPS for refractory ascites in cirrhosis as a way to prevent HRS
Intraoperative RRT for patients who were receiving preoperative RRTTIPS for refractory ascites in cirrhosis as a way to prevent HRS
