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Guidelines Detail Management of Liver Failure in ICU Patients

29 recommendations address CV, hematology, pulmonary, renal, endocrine considerations

MONDAY, March 9, 2020 (HealthDay News) — In an executive summary of a new guideline from the Society of Critical Care Medicine, published in the March issue of Critical Care Medicine, a set of evidence-based recommendations are presented for the management of liver failure in critically ill patients.

Rahul Nanchal, M.D., from the Medical College of Wisconsin in Milwaukee, and colleagues developed 29 recommendations on management of acute liver failure (ALF) or acute-on-chronic liver failure (ACLF) in the intensive care unit, with cardiovascular, hematology, pulmonary, renal, and endocrine considerations.

Six of the recommendations were strong. For initial fluid resuscitation of patients with ALF or ACLF, the authors recommend against use of hydroxyethyl starch. Gelatin solutions are not suggested for initial fluid resuscitation, while albumin is suggested over other fluids. For patients who remain hypotensive despite fluid resuscitation or those with profound hypotension and tissue hypoperfusion even if fluid resuscitation is ongoing, norepinephrine is recommended as a first-line vasopressor. In critically ill patients undergoing procedures, viscoelastic testing is recommended over measuring the international normalized ratio, platelet, and fibrinogen. In ACLF patients with thrombocytopenia prior to surgery/invasive procedures, Eltrombopag is not recommended. Vasopressors are recommended in critically ill patients with ACLF who develop hepatorenal syndrome. A serum blood glucose of 110 to 180 mg/dL should be targeted in patients with ALF or ACLF.

“These guidelines are meant to supplement and not replace an individual clinician’s cognitive decision making,” the authors write.

One author disclosed serving as an expert witness regarding the treatment of hepatitis C virus infection.

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