Guidelines GI and Nutrition Quality and Patient Safety

Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure (Part I)

PUBLISHED: 02/14/2020

Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure (Part I)

Citation: Crit Care Med. 2020 March;48(3):415-419

Acute liver failure (ALF) and acute on chronic liver failure (ACLF) are conditions frequently encountered in the ICU and are associated with high mortality. The purpose of these guidelines was to develop evidence-based recommendations addressing common clinical questions surrounding the unique manifestations of liver failure in the critically ill patient.

Often, clinical care must be adapted to individual clinical circumstances and patient/family preferences. These guidelines are meant to supplement and not replace an individual clinician’s cognitive decision-making. The primary goal of these guidelines is to aid best practice and not represent standard of care.

METHODS
Co-chair and vice-chairs were appointed by the Society of Critical Care Medicine (SCCM). Twenty-five other panel members were chosen in accordance with their clinical and/or methodological expertise. Corresponding with individual expertise, the panel was then divided into nine subgroups; the recommendations of five of those subgroups (cardiovascular, hematology, pulmonary, renal, and endocrine) are presented in this document. Each panel member followed all conflict of interest procedures as documented in the American College of Critical Care Medicine/SCCM Standard Operating Procedures Manual. The panel proposed, discussed, and finally developed 30 Population Intervention Comparator Outcome questions which they deemed most important to the patient and the end-users of this guideline. We used Grading Recommendations, Assessment, Development, and Evaluation (GRADE) approach to prioritize outcomes, assess quality of evidence, and determine the strength of outcomes. We then used the Evidence-to-Decision framework to facilitate transition from evidence to final recommendations. We classified each recommendation as strong or conditional as per GRADE methodology. We accepted a recommendation if 80% consensus was achieved among at least 75% of panel members. We developed best practice statements as ungraded strong recommendations in adherence with strict conditions.

RESULTS
We report 29 recommendations on the management acute or ACLF in the ICU, related to five groups (cardiovascular, hematology, pulmonary, renal, and endocrine). Overall, six were strong recommendations, 19 were conditional recommendations, four were best practice statements, and in two instances, a recommendation was not issued because due to insufficient evidence. We discuss the abbreviated rationale for the six strong recommendations. The full recommendations and complete rationales can be found in the main article published in critical care medicine.

Guideline Type: Clinical

Related Resources:
Liver Guidelines Recommendations Table

Read Full Guideline

We recommend against using hydroxyethyl starch for initial fluid resuscitation of patients with acute liver failure or acute on chronic liver failure.
Quality of Evidence: Moderate

Cardiovascular Strong

We suggest against using gelatin solutions for initial fluid resuscitation of patients with acute liver failure or acute on chronic liver failure.
Quality of Evidence: Low

Cardiovascular Conditional

We suggest using albumin for resuscitation of patients with acute liver failure or acute on chronic liver failure over other fluids, especially when serum albumin is low (<3 mg/dL).
Quality of Evidence: Low

Cardiovascular Conditional

We suggest targeting a mean arterial pressure (MAP) of 65 mm Hg in patients with acute liver failure or acute on chronic liver failure over other fluids, especially when serum albumin is low (<3mg/dL), with concomitant assessment of perfusion.
Quality of Evidence: Low

Remarks

Some patients will have adequate perfusion at a lower MAP, and others will have improvement of perfusion at a higher MAP.

Cardiovascular Conditional

We suggest placing an arterial catheter for blood pressure monitoring in patients with acute liver failure or acute on chronic liver failure and shock.
Quality of Evidence: Low

Cardiovascular Conditional

We suggest using invasive hemodynamic monitoring to guide therapy in patients with acute liver failure or acute on chronic liver failure and clinically impaired perfusion.
Quality of Evidence: Low

Cardiovascular Conditional

We recommend using norepinephrine as a first-line vasopressor in patients with acute liver failure or acute on chronic liver failure who remain hypotensive despite fluid resuscitation, or those with profound hypotension and tissue hypoperfusion even if fluid resuscitation is ongoing.
Quality of Evidence: Moderate

Cardiovascular Strong

We suggest adding low-dose vasopressin to norepinephrine in patients with acute liver failure or acute on chronic liver failure who remain hypotensive despite fluid resuscitation to increase blood pressure.
Quality of Evidence: Low

Cardiovascular Conditional

We suggest using viscoelastic testing (thromboelastography/rotational thromboelastometry [ROTEM]) over measuring international normalized ratio (INR), platelet, and fibrinogen in critically ill patients with acute liver failure or acute on chronic liver failure.
Quality of Evidence: Low

Hematology Conditional

We suggest using a transfusion threshold of 7 mg/dL, over other thresholds, for critically ill patients with acute liver failure or acute on chronic liver failure.
Quality of Evidence: Low

Hematology Conditional

We suggest using low molecular weight heparin (LMWH) or vitamin K antagonists, over no anticoagulation, in patients with portal venous thrombosis or pulmonary embolus.
Quality of Evidence: Very Low

Hematology Conditional

We suggest using low molecular weight heparin over pneumatic compression stockings for venous thromboembolism prophylaxis in hospitalized patients withacute on chronic liver failure.
Quality of Evidence: Low

Remarks

There is insufficient evidence to allow a recommendation for patients with ALF.

Hematology Conditional

We recommend viscoelastic testing (thromboelastography/ROTEM), over measuring INR, platelet, fibrinogen, in critically ill patients with acute liver failure or acute on chronic liver failure undergoing procedures.
Quality of Evidence: Moderate

Hematology Strong

We recommend against using Eltrombopag in acute on chronic liver failure patients with thrombocytopenia prior to surgery/invasive procedures.
Quality of Evidence: Low

Remarks

There is insufficient evidence to issue a recommendation for or against prothrombin complex concentrates
(PCCs).

Hematology Strong

We suggest using a low tidal volume strategy over high tidal volume strategy in patients with acute liver failure or acute on chronic liver failure and acute respiratory distress syndrome.
Quality of Evidence: Low

Pulmonary Conditional

We suggest against using high PEEP, over low PEEP, in patients with acute liver failure or acute on chronic liver failure and acute respiratory distress syndrome.
Quality of Evidence: Low

Remarks

Clinicians may cautiously choose high PEEP in moderate to severe ARDS after balancing potential benefit to risk of increasing intracranial pressure (ICP) and reducing venous return.

Pulmonary Conditional

We suggest treating portopulmonary hypertension (POPH) with agents approved for pulmonary arterial hypertension (PAH) in patients with mean pulmonary artery pressure greater than 35mm Hg.
Quality of Evidence: Very Low

Pulmonary Conditional

We recommend supportive care with supplemental oxygen in the treatment of hepatopulmonary syndrome (HPS), pending possible liver transplantation.

Pulmonary Best-Practice

We recommend placing chest tube with an attempt to pleurodesis for hepatic hydrothorax in patients in whom transjugular intrahepatic portosystemic shunt (TIPS) is not an option or as a palliative intent.

Pulmonary Best-Practice

We suggest using high-flow nasal cannula (HFNC) over noninvasive ventilation in hypoxic critically ill patients with acute liver failure or acute on chronic liver failure.
Quality of Evidence: Low

Remarks

In patients with hypercarbia, it may be more appropriate to use noninvasive positive pressure ventilation (NIPPV) or invasive mechanical ventilation over HFNC.

Pulmonary Conditional

We suggest using RRT early in patients with ALF and AKI.
Quality of Evidence: Very Low

Remarks

There is insufficient evidence to issue a recommendation for the acute on chronic liver failure population. Early initiation of RRT is defined as initiation of RRT before 1) hyperkalemia (> 6 mmol/L with electrocardiographic abnormalities), 2) fluid overload/pulmonary edema resistant to diuretic administration, 3) severe metabolic acidosis (pH < 7.15), 4) blood urea concentration greater than 35.7 mmol/L, or 5) Kidney Disease Improving Global Outcomes stage 3 AKI.

Renal Conditional

We recommend using vasopressors, over not using vasopressors, in critically ill patients with acute on chronic liver failure who develop hepatorenal syndrome (HRS).
Quality of Evidence: Moderate

Remarks

Vasopressors could be any of the following: terlipressin, norepinephrine, or midodrine and octreotide.

Renal Strong

We recommend targeting a serum blood glucose of 110-180 mg/dL in patients with acute liver failure or acute on chronic liver failure.
Quality of Evidence: Moderate

Endocrine-Nutrition Strong

We suggest using stress-dose glucocorticoids in the treatment of septic shock in patients with acute liver failure or acute on chronic liver failure.
Quality of Evidence: Low

Remarks

Stress dose glucocorticoids should be used if adequate fluid resuscitation and vasopressor agents are unable to restore hemodynamic stability.

Endocrine-Nutrition Conditional

We suggest against using a low protein goal in patients with acute liver failure or acute on chronic liver failure, but rather targeting protein goals comparable with critically ill patients without liver failure (1.2– 2.0g protein/kg dry or ideal body weight per day [IBW/d]).
Quality of Evidence: Very Low

Endocrine-Nutrition Conditional

We suggest not using branched-chain amino acids (BCAAs) in critically ill patients hospitalized with acute liver failure or acute on chronic liver failure who are tolerating enteral medications.
Quality of Evidence: Very Low

Endocrine-Nutrition Conditional

We suggest enteral nutrition (EN) over parenteral nutrition (PN) in critically ill patients hospitalized withacute liver failure or acute on chronic liver failure without contraindication for enteral feeding.
Quality of Evidence: Low

Endocrine-Nutrition Conditional

We recommend screening patients with acute liver failure or acute on chronic liver failure for drug-induced causes of liver failure. Drug that are proven or highly suspected to be the cause of acute liver failure or acute on chronic liver failure should be discontinued.

Endocrine-Nutrition Best-Practice

In patients with acute liver failure or acute on chronic liver failure, we recommend adjusting the doses of medications that undergo hepatic metabolism based on the patient’s residual hepatic function and using the best available literature. When available, a clinical pharmacist should be consulted.

Endocrine-Nutrition Best-Practice

A complete list of the guidelines authors and contributors is available within the published manuscript.

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