Management of Decompensated cirrhosis in surgical ICU: Clinical consensus statement
USA: The American Association for the Surgery of Trauma Critical Care Committee has released a consensus document on the management of decompensated cirrhosis (DC) in the surgical ICU.
The clinical consensus document, published in the BMJ journal Trauma Surgery & Acute Care Open, reviews practical clinical questions about the critical care management of patients with DC to facilitate best practices by the bedside provider.
Decompensated cirrhosis is a common clinical entity, affecting about 10.6 million people globally in 2017, and the number of cases has more than tripled since 1990. In the surgical ICU, patients with DC are particularly difficult to manage due to their comorbidities related to underlying liver dysfunction.
The clinical consensus document addresses several important practical considerations for intensivists in the care of the critically ill patient with DC, including end points of resuscitation, ascites management, and avoidance of postparacentesis circulatory dysfunction (PPCD), gastrointestinal (GI) bleeding, venous thromboembolism (VTE) prophylaxis, management of hepatic encephalopathy (HE) and nutritional support.
Volume Status
Recommendation
- Pulmonary artery catheter measurements, mean arterial pressure, pulse pressure variation, point of care transthoracic echocardiography (TTE), and arterial pulse contour technology can all be used in volume assessment of patients with DC, with the understanding of their limitations in this patient population. Typical end points of resuscitation can be used in DC; however, mixed venous oxygen saturation (SvO2) and serum lactate should be interpreted cautiously.
Fluid Resuscitation and Vasopressors
Recommendation
- Balanced salt solutions should be used over normal saline. Norepinephrine is the vasopressor of choice. Albumin is useful in patients with spontaneous bacterial peritonitis (SBP), hepatorenal syndrome (HRS), and PPCD.
Ascites Management
Recommendation
- Preoperative ascites control should include sodium restriction and diuretics for grade 2 ascites and LVP with albumin administration for grade 3 ascites. Transjugular intrahepatic portosystemic shunt (TIPS) should be considered preoperatively in patients undergoing elective hernia repair with ascites refractory to medical management.
- Albumin administration can be considered as part of intraoperative fluid management to help avoid PPCD related to intraoperative ascites evacuation, based on its benefit in PPCD prevention in non-operative situations such as LVP. TIPS should be considered postoperatively in patients with ascites that are refractory to medical management.
Hepatorenal Syndrome
Recommendation
· HRS-AKI is defined as an increase in serum creatinine ≥0.3 mg/dL within 48 hours or ≥50% increase in serum creatinine within the preceding 7 days in patients with cirrhosis and ascites in the absence of structural kidney disease. Management includes volume expansion with albumin, treatment of infections, stopping diuretics, and use of terlipressin or norepinephrine for MAP >65 mm Hg.
Gastrointestinal Bleeding
Recommendation
· Patients with DC with gastrointestinal bleeding (GIB) should receive ceftriaxone and a vasoactive agent (vasopressin, somatostatin, or octreotide). Ventilated patients with upper GIB (UGIB) should receive a proton pump inhibitor (PPI). Viscoelastic testing (VET) can guide use of VTE prophylaxis. Transfusion should be performed with goal hemoglobin (Hb) of 7–8 g/dL (70-80 g/L). Endoscopy should be performed within 12 hours and TIPS should be considered for recurrent or persistent variceal bleeding.
Coagulopathy
Recommendation
· The timing of VTE prophylaxis initiation should not differ from patients without DC, regardless of standard coagulation test results. In cases of clinical uncertainty, normal or hypercoagulable VET may be an appropriate trigger to initiate prophylaxis. Anti-factor Xa monitoring is not recommended.
· Empiric platelet transfusions are not indicated for the peri-procedural correction of thrombocytopenia unless VET indicates a functional platelet deficit.
Hepatic Encephalopathy
Recommendation
- Ammonia levels should be obtained to exclude or implicate HE as an etiology of altered mental status, but not to follow its progression or response to therapy. Initial treatment should include non-absorbable disaccharides and rifaximin.
Nutrition
Recommendation
- Early enteral nutrition is preferred for patients with DC. Protein restriction is not beneficial. Hypoglycemia should be managed with frequent blood glucose measurements and dextrose if needed.
Prognosis
Recommendation
- Clinical scores including the MELD, Acute-on-Chronic Liver Failure (ACLF) criteria, and the Chronic Liver Failure-Sequential Organ Failure Assessment (SOFA) (CLIF-SOFA) can be used to predict outcomes in DC. Biomarkers including cystatin C, copeptin, procalcitonin, and C reactive protein are under investigation to predict outcomes in DC but are not recommended for routine use at this time.
Reference:
Seshadri A, Appelbaum R, Carmichael SP, et alManagement of Decompensated Cirrhosis in the Surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus DocumentTrauma Surgery & Acute Care Open 2022;7:e000936. doi: 10.1136/tsaco-2022-000936
