Skip to main content

Advertisement

SpringerLink
Log in

Intensive Care Management of Patients with Cirrhosis

  • Liver (J Bajaj, Section Editor)
  • Published:
Current Treatment Options in Gastroenterology Aims and scope Submit manuscript

Abstract

Purpose of review

Cirrhosis is a major worldwide health problem which results in a high level of morbidity and mortality. Patients with cirrhosis who require intensive care support have high mortality rates of near 50%. The goal of this review is to address the management of common complications of cirrhosis in the ICU.

Recent findings

Recent epidemiological studies have shown an increase in hospitalizations due to advanced liver disease with an associated increase in intensive care utilization. Given an increasing burden on the healthcare system, it is imperative that we strive to improve our management cirrhotic patients in the intensive care unit.

Summary

Large studies evaluating the management of patients in the intensive care setting are lacking. To date, most recommendations are based on extrapolation of data from studies in cirrhosis outside of the ICU or by applying general critical care principles which may or may not be appropriate for the critically ill cirrhotic patient. Future research is required to answer important management questions.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Schuppan D, Afdhal NH. Liver cirrhosis. Lancet. 2008;371(9615):838–51. https://doi.org/10.1016/s0140-6736(08)60383-9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Moreau R, Jalan R, Gines P, Pavesi M, Angeli P, Cordoba J, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology. 2013;144(7):1426–37. e1–9. https://doi.org/10.1053/j.gastro.2013.02.042.

    Article  PubMed  Google Scholar 

  3. World Health Organization Global Health Estimates for Cause Specific Mortality 2012. http://www.who.int/healthinfo/global_burden_disease/estimates/en/index1.html. Accessed May 21, 2015 2015.

  4. Allen AM, Kim WR, Moriarty JP, Shah ND, Larson JJ, Kamath PS. Time trends in the health care burden and mortality of acute on chronic liver failure in the United States. Hepatology. 2016;64(6):2165–72. https://doi.org/10.1002/hep.28812.

    Article  PubMed  Google Scholar 

  5. Olson JC, Wendon JA, Kramer DJ, Arroyo V, Jalan R, Garcia-Tsao G, et al. Intensive care of the patient with cirrhosis. Hepatology. 2011;54(5):1864–72. https://doi.org/10.1002/hep.24622.

  6. McPhail MJW, Parrott F, Wendon JA, Harrison DA, Rowan KA, Bernal W. Incidence and outcomes for patients with cirrhosis admitted to the United Kingdom critical care units. Crit Care Med. 2018:1. https://doi.org/10.1097/ccm.0000000000002961.

  7. Welzel TM, Domenicali M, Risso A, Wendon J, Deulofeu C, Angeli P, et al. Hepatic encephalopathy--definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th world congresses of gastroenterology, Vienna, 1998. Hepatology. 2002;35(3):716–21. https://doi.org/10.1002/hep.27849; https://doi.org/10.1053/jhep.2002.31250.

  8. Cordoba J, Ventura-Cots M, Simon-Talero M, Amoros A, Pavesi M, Vilstrup H, et al. Characteristics, risk factors, and mortality of cirrhotic patients hospitalized for hepatic encephalopathy with and without acute-on-chronic liver failure (ACLF). J Hepatol. 2014;60(2):275–81. https://doi.org/10.1016/j.jhep.2013.10.004.

    Article  PubMed  Google Scholar 

  9. Cadranel JF, Lebiez E, Di Martino V, Bernard B, El Koury S, Tourbah A, et al. Focal neurological signs in hepatic encephalopathy in cirrhotic patients: an underestimated entity? Am J Gastroenterol. 2001;96(2):515–8. https://doi.org/10.1111/j.1572-0241.2001.03552.x.

    Article  CAS  PubMed  Google Scholar 

  10. Kramer L, Tribl B, Gendo A, Zauner C, Schneider B, Ferenci P, et al. Partial pressure of ammonia versus ammonia in hepatic encephalopathy. Hepatology. 2000;31(1):30–4. https://doi.org/10.1002/hep.510310107.

  11. Rahimi RS, Rockey DC. Overuse of head computed tomography in cirrhosis with altered mental status. Am J Med Sci. 2016;351(5):459–66. https://doi.org/10.1016/j.amjms.2016.02.022.

    Article  PubMed  Google Scholar 

  12. Haj M, Totin L, Rockey DC. Rectal or oral lactulose in patients admitted with hepatic encephalopathy. Hepatology. 2017;66(1 SUPPL):279A–80A.

    Google Scholar 

  13. Haj M, Rockey DC. Lactulose-induced hypernatremia in patients with hepatic encephalopathy. Hepatology. 2017;66(1 SUPPL):277A–8A.

    Google Scholar 

  14. • Rahimi RS, Singal AG, Cuthbert JA, Rockey DC. Lactulose vs polyethylene glycol 3350—electrolyte solution for treatment of overt hepatic encephalopathy: the HELP randomized clinical trial. JAMA Intern Med. 2014;174(11):1727–33. https://doi.org/10.1001/jamainternmed.2014.4746. Though underpowered, this study demonstrates an alternaltive strategy for treating encephalopathy that has numerous implications for patients in the ICU.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Bass NM, Mullen KD, Sanyal A, Poordad F, Neff G, Leevy CB, et al. Rifaximin treatment in hepatic encephalopathy. N Engl J Med. 2010;362(12):1071–81. https://doi.org/10.1056/NEJMoa0907893.

  16. Sharma BC, Sharma P, Lunia MK, Srivastava S, Goyal R, Sarin SK. A randomized, double-blind, controlled trial comparing rifaximin plus lactulose with lactulose alone in treatment of overt hepatic encephalopathy. Am J Gastroenterol. 2013;108(9):1458–63. https://doi.org/10.1038/ajg.2013.219.

    Article  CAS  PubMed  Google Scholar 

  17. Jalan R, Wright G, Davies NA, Hodges SJ. L-Ornithine phenylacetate (OP): a novel treatment for hyperammonemia and hepatic encephalopathy. Med Hypotheses. 2007;69(5):1064–9. https://doi.org/10.1016/j.mehy.2006.12.061.

    Article  CAS  PubMed  Google Scholar 

  18. Ventura-Cots M, Arranz JA, Simon-Talero M, Torrens M, Blanco A, Riudor E, et al. Safety of ornithine phenylacetate in cirrhotic decompensated patients: an open-label, dose-escalating, single-cohort study. J Clin Gastroenterol. 2013;47(10):881–7. https://doi.org/10.1097/MCG.0b013e318299c789.

    Article  CAS  PubMed  Google Scholar 

  19. Ventura-Cots M, Concepcion M, Arranz JA, Simon-Talero M, Torrens M, Blanco-Grau A, et al. Impact of ornithine phenylacetate (OCR-002) in lowering plasma ammonia after upper gastrointestinal bleeding in cirrhotic patients. Ther Adv Gastroenterol. 2016;9(6):823–35. https://doi.org/10.1177/1756283x16658252.

    Article  CAS  Google Scholar 

  20. Stravitz RT, Gottfried M, Durkalski V, Fontana RJ, Hanje AJ, Koch D et al. Safety, tolerability, and pharmacokinetics of l-ornithine phenylacetate in patients with acute liver injury/failure and hyperammonemia. 2017. https://doi.org/10.1002/hep.29621

  21. Safadi R, Rahimi RS, DiLiberti CE, Wang L, Pyrsopoulos NT, Potthoff A, et al. OCR-002 (ornithine phenylacetate) is a potent ammonia scavenger as demonstrated in phase 2b STOP-HE study. Hepatology. 2017;66(1 Suppl):126A.

    Google Scholar 

  22. • Bakti G, Fisch HU, Karlaganis G, Minder C, Bircher J. Mechanism of the excessive sedative response of cirrhotics to benzodiazepines: model experiments with triazolam. Hepatology. 1987;7(4):629–38. Though this was a small study, it is instructive as to the important impact of benzodiazepines on neurocognitive function in cirrhotic patients.

    Article  CAS  PubMed  Google Scholar 

  23. Feys HB, Canciani MT, Peyvandi F, Deckmyn H, Vanhoorelbeke K, Mannucci PM. ADAMTS13 activity to antigen ratio in physiological and pathological conditions associated with an increased risk of thrombosis. Br J Haematol. 2007;138(4):534–40. https://doi.org/10.1111/j.1365-2141.2007.06688.x.

    Article  CAS  PubMed  Google Scholar 

  24. Lisman T, Bongers TN, Adelmeijer J, Janssen HL, de Maat MP, de Groot PG, et al. Elevated levels of von Willebrand factor in cirrhosis support platelet adhesion despite reduced functional capacity. Hepatology. 2006;44(1):53–61. https://doi.org/10.1002/hep.21231.

    Article  CAS  PubMed  Google Scholar 

  25. Lisman T, Porte RJ. Rebalanced hemostasis in patients with liver disease: evidence and clinical consequences. Blood. 2010;116(6):878–85. https://doi.org/10.1182/blood-2010-02-261891.

    Article  CAS  PubMed  Google Scholar 

  26. Alamo JM, Leon A, Mellado P, Bernal C, Marin LM, Cepeda C, et al. Is “intra-operating room” thromboelastometry useful in liver transplantation? A case-control study in 303 patients. Transplant Proc. 2013;45(10):3637–9. https://doi.org/10.1016/j.transproceed.2013.11.008.

    Article  PubMed  Google Scholar 

  27. Shore-Lesserson L, Manspeizer HE, DePerio M, Francis S, Vela-Cantos F, Ergin MA. Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Anesth Analg. 1999;88(2):312–9.

    CAS  PubMed  Google Scholar 

  28. De Pietri L, Bianchini M, Montalti R, De Maria N, Di Maira T, Begliomini B, et al. Thrombelastography-guided blood product use before invasive procedures in cirrhosis with severe coagulopathy: a randomized, controlled trial. Hepatology. 2016;63(2):566–73. https://doi.org/10.1002/hep.28148.

    Article  PubMed  Google Scholar 

  29. Northup PG, McMahon MM, Ruhl AP, Altschuler SE, Volk-Bednarz A, Caldwell SH, et al. Coagulopathy does not fully protect hospitalized cirrhosis patients from peripheral venous thromboembolism. Am J Gastroenterol. 2006;101(7):1524–8, quiz 680. https://doi.org/10.1111/j.1572-0241.2006.00588.x.

  30. Gulley D, Teal E, Suvannasankha A, Chalasani N, Liangpunsakul S. Deep vein thrombosis and pulmonary embolism in cirrhosis patients. Dig Dis Sci. 2008;53(11):3012–7. https://doi.org/10.1007/s10620-008-0265-3.

    Article  PubMed  Google Scholar 

  31. Wu H, Nguyen GC. Liver cirrhosis is associated with venous thromboembolism among hospitalized patients in a nationwide US study. Clin Gastroenterol Hepatol. 2010;8(9):800–5. https://doi.org/10.1016/j.cgh.2010.05.014.

    Article  PubMed  Google Scholar 

  32. Grabau CM, Crago SF, Hoff LK, Simon JA, Melton CA, Ott BJ, et al. Performance standards for therapeutic abdominal paracentesis. Hepatology. 2004;40(2):484–8.

  33. Tripodi A, Primignani M, Chantarangkul V, Clerici M, Dell'Era A, Fabris F, et al. Thrombin generation in patients with cirrhosis: the role of platelets. Hepatology. 2006;44(2):440–5.

  34. Youssef WI, Salazar F, Dasarathy S, Beddow T, Mullen KD. Role of fresh frozen plasma infusion in correction of coagulopathy of chronic liver disease: a dual phase study. Am J Gastroenterol. 2003;98(6):1391–4. https://doi.org/10.1111/j.1572-0241.2003.07467.x.

    Article  PubMed  Google Scholar 

  35. • Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American association for the study of liver diseases. Hepatology. 2017;65(1):310–35. https://doi.org/10.1002/hep.28906. Practice guideline with extensive review of evidence regarding management of portal hypertensive bleeding. A valuable resoruce for any provider who treats a high volume of cirrhotic patients in the ICU.

    Article  PubMed  Google Scholar 

  36. Escorsell A, Pavel O, Cardenas A, Morillas R, Llop E, Villanueva C, et al. Esophageal balloon tamponade versus esophageal stent in controlling acute refractory variceal bleeding: a multicenter randomized, controlled trial. Hepatology. 2016;63(6):1957–67. https://doi.org/10.1002/hep.28360.

    Article  PubMed  Google Scholar 

  37. Garcia-Pagan JC, Di Pascoli M, Caca K, Laleman W, Bureau C, Appenrodt B, et al. Use of early-TIPS for high-risk variceal bleeding: results of a post-RCT surveillance study. J Hepatol. 2013;58(1):45–50. https://doi.org/10.1016/j.jhep.2012.08.020.

    Article  PubMed  Google Scholar 

  38. Wells M, Chande N, Adams P, Beaton M, Levstik M, Boyce E, et al. Meta-analysis: vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther. 2012;35(11):1267–78. https://doi.org/10.1111/j.1365-2036.2012.05088.x.

  39. Bernard B, Grange JD, Khac EN, Amiot X, Opolon P, Poynard T. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology. 1999;29(6):1655–61.

    Article  CAS  PubMed  Google Scholar 

  40. Borzio M, Salerno F, Piantoni L, Cazzaniga M, Angeli P, Bissoli F, et al. Bacterial infection in patients with advanced cirrhosis: a multicentre prospective study. Dig Liver Dis : Off J Italian Soc Gastroenterol Italian Assoc Study Liver. 2001;33(1):41–8.

  41. de Franchis R. Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63(3):743–52. https://doi.org/10.1016/j.jhep.2015.05.022.

    Article  PubMed  Google Scholar 

  42. Piano S, Rosi S, Maresio G, Fasolato S, Cavallin M, Romano A, et al. Evaluation of the acute kidney injury network criteria in hospitalized patients with cirrhosis and ascites. J Hepatol. 2013;59(3):482–9. https://doi.org/10.1016/j.jhep.2013.03.039.

  43. Tsien CD, Rabie R, Wong F. Acute kidney injury in decompensated cirrhosis. Gut. 2013;62(1):131–7. https://doi.org/10.1136/gutjnl-2011-301255.

    Article  PubMed  Google Scholar 

  44. Alessandria C, Ottobrelli A, Debernardi-Venon W, Todros L, Cerenzia MT, Martini S, et al. Noradrenalin vs terlipressin in patients with hepatorenal syndrome: a prospective, randomized, unblinded, pilot study. J Hepatol. 2007;47(4):499–505. https://doi.org/10.1016/j.jhep.2007.04.010.

  45. Boyer TD, Sanyal AJ, Wong F, Frederick RT, Lake JR, O'Leary JG, et al. Terlipressin plus albumin is more effective than albumin alone in improving renal function in patients with cirrhosis and hepatorenal syndrome type 1. Gastroenterology. 2016;150(7):1579–89.e2. https://doi.org/10.1053/j.gastro.2016.02.026.

    Article  CAS  PubMed  Google Scholar 

  46. Cavallin M, Kamath PS, Merli M, Fasolato S, Toniutto P, Salerno F, et al. Terlipressin plus albumin versus midodrine and octreotide plus albumin in the treatment of hepatorenal syndrome: a randomized trial. Hepatology. 2015;62(2):567–74. https://doi.org/10.1002/hep.27709.

  47. Israelsen M, Krag A, Allegretti AS, Jovani M, Goldin AH, Winter RW, et al. Terlipressin versus other vasoactive drugs for hepatorenal syndrome. Cochrane Database Syst Rev. 2017;9:Cd011532. https://doi.org/10.1002/14651858.CD011532.pub2.

    PubMed  Google Scholar 

  48. Nassar Junior AP, Farias AQ, LA DA, Carrilho FJ, Malbouisson LM. Terlipressin versus norepinephrine in the treatment of hepatorenal syndrome: a systematic review and meta-analysis. PLoS One. 2014;9(9):e107466. https://doi.org/10.1371/journal.pone.0107466.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Sanyal AJ, Boyer T, Garcia-Tsao G, Regenstein F, Rossaro L, Appenrodt B, et al. A randomized, prospective, double-blind, placebo-controlled trial of terlipressin for type 1 hepatorenal syndrome. Gastroenterology. 2008;134(5):1360–8. https://doi.org/10.1053/j.gastro.2008.02.014.

  50. Sanyal AJ, Boyer TD, Frederick RT, Wong F, Rossaro L, Araya V, et al. Reversal of hepatorenal syndrome type 1 with terlipressin plus albumin vs. placebo plus albumin in a pooled analysis of the OT-0401 and REVERSE randomised clinical studies. Aliment Pharmacol Ther. 2017;45(11):1390–402. https://doi.org/10.1111/apt.14052.

  51. Skagen C, Einstein M, Lucey MR, Said A. Combination treatment with octreotide, midodrine, and albumin improves survival in patients with type 1 and type 2 hepatorenal syndrome. J Clin Gastroenterol. 2009;43(7):680–5. https://doi.org/10.1097/MCG.0b013e318188947c.

    Article  CAS  PubMed  Google Scholar 

  52. Velez JC, Nietert PJ. Therapeutic response to vasoconstrictors in hepatorenal syndrome parallels increase in mean arterial pressure: a pooled analysis of clinical trials. Am J Kidney Dis : Off J Nat Kidney Foundation. 2011;58(6):928–38. https://doi.org/10.1053/j.ajkd.2011.07.017.

    Article  CAS  Google Scholar 

  53. Nazar A, Pereira GH, Guevara M, Martin-Llahi M, Pepin MN, Marinelli M, et al. Predictors of response to therapy with terlipressin and albumin in patients with cirrhosis and type 1 hepatorenal syndrome. Hepatology. 2010;51(1):219–26. https://doi.org/10.1002/hep.23283.

    Article  CAS  PubMed  Google Scholar 

  54. •• Nadim MK, Durand F, Kellum JA, Levitsky J, O'Leary JG, Karvellas CJ, et al. Management of the critically ill patient with cirrhosis: a multidisciplinary perspective. J Hepatol. 2016;64(3):717–35. https://doi.org/10.1016/j.jhep.2015.10.019. A review of management of the critically ill cirrhotic patient written by a multidiscliplinary team with grading of evidence.

    Article  PubMed  Google Scholar 

  55. Cardoso FS, Gottfried M, Tujios S, Olson JC, Karvellas CJ. Continuous renal replacement therapy is associated with reduced serum ammonia levels and mortality in acute liver failure. 2017. https://doi.org/10.1002/hep.29488.

  56. Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, et al. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001;33(2):464–70.

  57. Kim WR, Biggins SW, Kremers WK, Wiesner RH, Kamath PS, Benson JT, et al. Hyponatremia and mortality among patients on the liver-transplant waiting list. N Engl J Med. 2008;359(10):1018–26. https://doi.org/10.1056/NEJMoa0801209.

  58. •• Gustot T, Fernandez J, Garcia E, Morando F, Caraceni P, Alessandria C, et al. Clinical course of acute-on-chronic liver failure syndrome and effects on prognosis. Hepatology. 2015;62(1):243–52. https://doi.org/10.1002/hep.27849. A detailed review of ACLF and the impact of the CLIF-C ACLFs scoring system on prognosis.

  59. Poonja Z, Brisebois A, van Zanten SV, Tandon P, Meeberg G, Karvellas CJ. Patients with cirrhosis and denied liver transplants rarely receive adequate palliative care or appropriate management. Clin Gastroenterol Hepatol. 2014;12(4):692–8. https://doi.org/10.1016/j.cgh.2013.08.027.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. University of Kansas Medical Center, 3901 Rainbow Blvd., MS 1023, Kansas City, Kansas, 66160, USA

    Jody C. Olson MD

Authors
  1. Jody C. Olson MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jody C. Olson MD.

Ethics declarations

Conflict of Interest

Jody Olson declares that he has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Liver

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Olson, J.C. Intensive Care Management of Patients with Cirrhosis. Curr Treat Options Gastro 16, 241–252 (2018). https://doi.org/10.1007/s11938-018-0182-2

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11938-018-0182-2

Keywords

Search

Navigation