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Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU (Part II)
Citation: Nanchal R, et al. Crit Care Med. 2023;51657-676.
OBJECTIVE:
Develop evidence-based recommendations for clinicians caring for adults with acute liver failure (ALF) or acute on chronic liver failure (ACLF) in the ICU
DESIGN:
The guideline panel comprised 27 members with expertise in aspects of care of the critically ill patient with liver failure or methodology. We adhered to the Society of Critical Care Medicine standard operating procedures manual and conflict-of-interest policy. Teleconferences and electronic-based discussion among the panel, as well as within subgroups, served as an integral part of the guideline development.
INTERVENTIONS:
In part 2 of this guideline, the panel was divided into four subgroups: neurology, peritransplant, infectious diseases, and gastrointestinal groups. We developed and selected Population, Intervention, Comparison, and Outcomes (PICO) questions according to importance to patients and practicing clinicians. For each PICO question, we conducted a systematic review and meta-analysis where applicable. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. We used the evidence to decision framework to facilitate recommendations formulation as strong or conditional. We followed strict criteria to formulate best practice statements.
MEASUREMENTS AND MAIN RESULTS:
We report 28 recommendations (from 31 PICO questions) on the management of ALF and ACLF in the ICU. Overall, five were strong recommendations, 21 were conditional recommendations, two were best-practice statements, and five had insufficient evidence so we were unable to issue a recommendation.
CONCLUSIONS:
Multidisciplinary, international experts formulated evidence-based recommendations for the management of ALF and ACLF patients in the ICU, acknowledging that most recommendations were based on low quality and indirect evidence.
Guideline Type: Clinical
We suggest not using invasive intracranial pressure (ICP) monitoring for critically ill ALF patients with advanced-grade encephalopathy.
Patient Population: ALF
Quality of Evidence: Very low
We suggest, when available, using plasma exchange in critically ill ALF patients who develop hyperammonemia.
Patient Population: ALF patients who develop hyperammonemia
Quality of Evidence: Low
We suggest using hypertonic saline in critically ill ALF patients who are at risk of developing intracranial hypertension.
Patient Population: ALF patients who are at risk of developing intracranial hypertension.
Quality of Evidence: Low
We suggest not routinely using induced moderate hypothermia (< 34°C) for critically ill ALF patients who are at risk of developing intracranial hypertension.
Patient Population: ALF patients who are at risk of developing intracranial hypertension
Quality of Evidence: Very low
We suggest using nonabsorbable disaccharides in critically ill ACLF patients with overt hepatic encephalopathy.
Patient Population: ACLF patients with overt hepatic encephalopathy
Quality of Evidence: Low
We suggest using enteral polyethylene glycol (PEG) as an alternative to lactulose in critically ill ACLF patients with overt hepatic encephalopathy.
Patient Population: ACLF patients with overt hepatic encephalopathy
Quality of Evidence: Low
We suggest using oral rifaximin as adjunctive therapy in critically ill patients ACLF patients with overt hepatic encephalopathy.
Patient population: ACLF patients with overt hepatic encephalopathy
Quality of Evidence: Low
We suggest using LOLA in critically ill ACLF patients with overt hepatic encephalopathy.
Patient population: ACLF patients with overt hepatic encephalopathy
Quality of Evidence: Very low
We suggest not routinely using IV flumazenil, probiotics, zinc supplementation, glycerol phenylbutyrate (GPB), or acarbose as adjunctive therapies in critically ill ACLF patients with overt hepatic encephalopathy.
Patient population: ACLF patients with overt hepatic encephalopathy
Quality of Evidence: Very low
We recommend using antibiotic prophylaxis in critically ill ACLF patients with any type of upper gastrointestinal bleeding (UGIB).
Patient population: ACLF patients with UGIB
Quality of Evidence: Moderate
We recommend using albumin in critically ill ACLF patients with SBP.
Patient population: ACLF patients with SBP
Quality of Evidence: Moderate
We suggest using systemic antifungal prophylaxis in critically ill liver transplant recipients with risk factors for invasive fungal infections.
Patient population: Liver transplant recipients with risk factors for invasive fungal infections
Quality of Evidence: Very low
We suggest not using antifungal prophylaxis in critically ill liver transplant recipients at low risk for invasive fungal infections.
Patient population: Liver transplant recipients at low risk for invasive fungal infections
Quality of Evidence: Very low
We suggest using appropriate antibiotics as soon as possible after recognition and within 1 hour of shock onset in critically ill ACLF patients with SBP and septic shock.
Patient population: ACLF patients with SBP and septic shock
Quality of Evidence: Low
We suggest not performing large volume paracentesis (LVP) in critically ill ACLF patients with SBP.
Patient population: ACLF patients with SBP
Quality of Evidence: Very low
We suggest not using selective bowel decontamination (SBD) for critically ill liver transplant recipients.
Patient population: Liver transplant recipients
Quality of Evidence: Low
We recommend using broad spectrum antibiotic agents for the initial management of SBP in critically ill ACLF patients.
Patient population: ACLF patients
Quality of Evidence: Low
We suggest not using midodrine or terlipressin empirically for critically ill ACLF patients with SBP.
Patient population: ACLF patients with SBP
Quality of Evidence: Very low
We recommend using proton pump inhibitors (PPIs) in critically ill ACLF patients with portal hypertensive bleeding.
Patient population: ACLF patients with portal hypertensive bleeding
Quality of Evidence: Low
We recommend using octreotide or somatostatin analog (SSA) for the treatment of portal hypertensive bleeding in critically ill patients with ACLF.
Patient population: ACLF patients with portal hypertensive bleeding
Quality of Evidence: Moderate
We suggest using transjugular intrahepatic portosystemic shunt (TIPS) for recurrent variceal bleeding after medical and endoscopic intervention over continued endoscopic therapy in critically ill ACLF patients.
Patient population: ACLF patients with variceal bleeding
Quality of Evidence: Low
We suggest using systemic corticosteroids for deceased liver graft donors.
Patient population: Deceased liver graft donors
Quality of Evidence: Very low
We suggest either using goal-directed fluid management for the deceased organ donor or standard fluid management strategies.
Patient population: Deceased organ donor
Quality of Evidence: Very low
We suggest using either extracorporeal liver support or standard medical therapy in critically ill ALF or ACLF patients.
Patient population: ALF or ACLF patients
Quality of Evidence: Very low
We suggest using balanced (or normochloremic) crystalloid solution over normal (hyperchloremic) saline for peri-transplant fluid replacement in liver transplant recipients.
Patient population: Liver transplant recipients
Quality of Evidence: Low
We suggest using albumin over crystalloid for intraoperative volume replacement during LT.
Patient population: Liver transplant recipients
Quality of Evidence: Low
There was insufficient evidence to issue a recommendation on using lactulose, rifaximin, flumazenil, branch-chain amino acids, carnitine, zinc, probiotics, and L-ornithine L-aspartate (LOLA) in critically ill ALF patients with hyperammonemia.
Patient Population: ALF patients with hyperammonemia
We recommend performing esophagogastroduodenoscopy no later than 12 hours of presentation in critically ill ACLF patients with portal hypertensive bleeding (known or suspected).
Patient Population: ACLF patients with portal hypertensive bleeding
We recommend performing LVP with measurement of intra-abdominal pressure in critically ill ACLF patients with tense ascites and intra-abdominal hypertension or hemodynamic, renal or respiratory compromise.
Patient Population: ACLF patients with tense ascites and intra-abdominal hypertension or hemodynamic, renal or respiratory compromise
There was insufficient evidence to issue a recommendation on using the donor risk index (DRI) in selection of liver allograft.
Patient Population: Organ donors and recipients
There was insufficient evidence to issue a recommendation on peri-transplant fluid restriction accompanied by vasopressor use in liver transplant recipients.
Patient Population: Liver transplant recipients
There was insufficient evidence to issue a recommendation for the choice of intraoperative monitoring in LT recipients.
Patient Population: Liver transplant recipients
There was insufficient evidence to issue recommendation on early extubation of liver transplant recipients.
Patient Population: Liver transplant recipients
A complete list of the guidelines authors and contributors is available within the published manuscript.
