Guidelines for the management of acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) in adult ICU patients

Severe Walker Translation Team Liang Yanyi Question 1 For critically ill patients with ALF or ACLF, do we recommend the use of hydroxyethyl starch or gelatin for initial resuscitation compared with crystalloids? Recommendation: We recommend against the use of hydroxyethyl starch during initial fluid resuscitation in patients with ALF or ACLF
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(strong recommendation, moderate-quality evidence)
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Rationale: Although the available evidence is limited by indirect factors (because few patients with liver failure were included in relevant studies), a meta-analysis of existing trials in critically ill On the one hand, hydroxyethyl starch is not superior to crystalloid
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Hydroxyethyl starch may exacerbate coagulopathy in liver failure, and the physiology of hydroxyethyl starch use in patients with liver failure is not convincing
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Question 2 Can norepinephrine be used as a first-line vasopressor in critically ill patients with ALF or ACLF who are still hypotensive after fluid resuscitation? Recommendation: For critically ill patients with ALF or ACLF who are still hypotensive after fluid resuscitation, or who are undergoing fluid resuscitation but have severe hypotension and tissue hypoperfusion, we recommend norepinephrine as a first-line Compression use (strong recommendation, moderate-quality evidence)
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Rationale: Patients with liver failure exhibit a state of circulatory hyperdynamics and shock, typical of the physiology of distributive shock
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Although there are few studies directly related to liver failure, indirect evidence from studies of other distributive shock states, such as septic shock, suggests that norepinephrine is superior to dopamine in that it reverses hypotension, with concomitant Lower mortality and arrhythmia risk
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Epinephrine can cause splanchnic vasoconstriction, increasing the risk of mesenteric and hepatic ischemia in the setting of liver failure
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There are no studies comparing vasopressin as a first-line drug with other vasoactive drugs
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Question 3 After invasive procedures or surgery in critically ill patients with ALF or ACLF, do we use the international prothrombin ratio (INR), platelet count, or fibrinogen level, or the viscoelasticity test ( Thromboelastometry TEG/Rotational Thromboelastometry (ROTEM)? Recommendation: In assessing bleeding risk in critically ill patients with ALF or ACLF undergoing invasive procedures or surgery, we recommend viscoelastic testing (thromboelastography TEG/rotational thromboelastometry ROTEM) rather than prothrombin international ratio (INR), platelet count, or fibrinogen level (strong recommendation, moderate-quality evidence)
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Rationale: Quantitative measurements of INR, platelet count, and fibrinogen levels do not provide a consistent assessment of overall hemostasis and bleeding risk
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The routine use of viscoelastic testing is an accepted method for determining systemic coagulation status in settings such as liver transplantation
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It provides a real-time global and functional assessment of changes in the activity of procoagulant and anticoagulant pathways, identifying platelet functional status, hyperfibrinolysis and premature thrombolysis
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In an open-label randomized controlled trial, the use of viscoelastic testing as a guide compared with the use of quantitative measures of INR or platelet count to guide blood product transfusion resulted in a significant reduction in blood product demand without an increase in Bleeding complications
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Question 4 For critically ill patients with ALF or ACLF, we can use novel hemostatic agents (prothrombin complexes, thrombopoietin receptor agonists, antifibrinolytics) to achieve pre-invasive or preoperative hematological targets , to reduce bleeding complications/transfusion? Recommendation: We recommend not using eltrombopag before surgery/invasive procedures in ACLF patients with thrombocytopenia (strong recommendation, moderate-quality evidence)
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Rationale: Thrombocytopenia is common in patients with ACLF
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Although compared with placebo, eltrombopag increased platelet counts in patients with chronic liver disease undergoing elective invasive procedures and resulted in significantly more patients avoiding platelet transfusions
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But it was also associated with thrombotic events in the portal venous system, leading to an early termination of the trial
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Although there are no data on the use of other novel hemostatic agents (eg, prothrombin complexes) in patients with ALF/ACLF, their use is limited by the inability to determine hemostatic function by traditional measures such as INR, fibrinogen, and platelet counts the impact of obstacles
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Question 5 Can we use vasopressors in critically ill patients with ACLF who develop hepatorenal syndrome (HRS)? Recommendation: We recommend the use of vasopressors, rather than their absence, in critically ill patients with ACLF who develop HRS (strong recommendation, moderate-quality evidence)
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Rationale: HRS is a unique form of kidney injury in patients with cirrhosis and ascites
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It occurs in approximately 20% of hospitalized patients with cirrhosis and AKI, predicting a very poor prognosis
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Vasopressors in combination with albumin remain a common treatment in the absence of liver transplantation
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Patients who received terlipressin were more likely to survive than those who received placebo, however, there was insufficient evidence to suggest that it was superior to other vasopressors (norepinephrine or midodrine in combination with octreotide)
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Question 6 For critically ill patients with ALF or ACLF with hyperglycemia, should we strictly control blood sugar (4.
44-6.
05 mmol/L) and also control blood sugar according to the general target (6.
11-10 mmol/L)? Recommendation: For critically ill patients with ALF or ACLF and hyperglycemia, we recommend a glycemic control target of 6.
11-10 mmol/L (strong recommendation, moderate-quality evidence)
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Rationale: The available evidence does not suggest a benefit of strict glycemic control compared with conventional glycemic control
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Strict glycemic control is associated with an increased risk of hypoglycemia
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In addition, patients with ALF/ACLF are at risk for hypoglycemia, which may be underestimated in these populations
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Glucose management in these patients should include the prevention of hypoglycemia to optimize their prognosis
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Summary table of recommendations: ACLF=acute-on-chronic liver failure, ALF=chronic liver failure, ARDS=acute respiratory distress syndrome, HRS=hepatorenal syndrome, LMWH=low molecular weight heparin, PEEP=positive end-expiratory pressure, RRT= Renal Replacement Therapy, TIPS=Transjugular Intrahepatic Portosystemic Shunt-END-Star Follow "The Last Dopamine" Wechat Public Account Wonderful Story Never Missing I used a stethoscope to measure the lives of one meet after another, And those lives that passed away in my hands explained the meaning of life to me with the tears that piled up in the corners of my eyes drop by drop
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