SCCM Resource Library-Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Cardiovascular, Endocrine, Hematologic, Pulmonary, and Renal Considerations

Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Cardiovascular, Endocrine, Hematologic, Pulmonary, and Renal Considerations

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Video Transcription

Video Summary

In this video, the speaker discusses the cardiovascular and pulmonary considerations in patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF). The recommendations are based on indirect evidence as there is limited direct evidence in this population. The first recommendation is against using hydroxyethyl starch or gelatin solutions for initial fluid resuscitation in ALF and ACLF patients. The rationale is that crystalloids are preferred over these solutions as there is no demonstrated benefit and potential risks. The use of albumin for resuscitation is suggested when serum albumin is low, as it may improve hemodynamics and prevent complications. Blood pressure targets should be aimed at maintaining a mean arterial pressure of 65 mmHg, with consideration for optimizing cerebral perfusion pressure in severe ALF patients. Arterial catheter placement for blood pressure monitoring and invasive hemodynamic monitoring to guide therapy for shock are suggested. Norepinephrine is recommended as the first-line vasopressor agent, with the addition of low-dose vasopressin if refractory to norepinephrine. In terms of pulmonary considerations, a low tidal volume strategy is recommended for mechanical ventilation in ALF and ACLF patients with ARDS, along with the use of positive end-expiratory pressure (PEEP) based on individual patient assessment. The use of pulmonary arterial hypertension therapy in portopulmonary hypertension and supportive care with supplemental oxygen in hepatopulmonary syndrome are also discussed. Lastly, high-flow nasal cannula is suggested over non-invasive ventilation for hypoxic critically ill patients with ALF or ACLF. The renal, hematologic, and endocrine considerations in these patient populations are also discussed in the video.

Asset Subtitle

GI and Nutrition, Renal, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

Learning Objectives

Apply new knowledge and strategies to optimize the care of the critically ill patient as provided by the multiprofessional team
Examine research results and evidence-based medicine techniques to evaluate and improve patient care
Review and integrate guidelines to measure performance and identify areas for further study and improvement

Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Cardiovascular and Pulmonary Considerations

Ram M. Subramanian

Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Endocrine, Hematologic and Renal Considerations

Constantine J. Karvellas

Meta Tag

Content Type Presentation

Knowledge Area Renal

Knowledge Area GI and Nutrition

Knowledge Level Advanced

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Liver

Tag Kidney

Year 2020

Keywords

cardiovascular

pulmonary

resuscitation

hemodynamics

mechanical ventilation

renal considerations

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