Acute liver failure (ALF) and acute on chronic liver failure (ACLF) are conditions frequently encountered in the ICU and are associated with high mortality. The purpose of these guidelines was to develop evidence-based recommendations addressing common clinical questions surrounding the unique manifestations of liver failure in the critically ill patient.
Often, clinical care must be adapted to individual clinical circumstances and patient/family preferences. These guidelines are meant to supplement and not replace an individual clinician’s cognitive decision-making. The primary goal of these guidelines is to aid best practice and not represent standard of care.
Co-chair and vice-chairs were appointed by the Society of Critical Care Medicine (SCCM). Twenty-five other panel members were chosen in accordance with their clinical and/or methodological expertise. Corresponding with individual expertise, the panel was then divided into nine subgroups; the recommendations of five of those subgroups (cardiovascular, hematology, pulmonary, renal, and endocrine) are presented in this document. Each panel member followed all conflict of interest procedures as documented in the American College of Critical Care Medicine/SCCM Standard Operating Procedures Manual. The panel proposed, discussed, and finally developed 30 Population Intervention Comparator Outcome questions which they deemed most important to the patient and the end-users of this guideline. We used Grading Recommendations, Assessment, Development, and Evaluation (GRADE) approach to prioritize outcomes, assess quality of evidence, and determine the strength of outcomes. We then used the Evidence-to-Decision framework to facilitate transition from evidence to final recommendations. We classified each recommendation as strong or conditional as per GRADE methodology. We accepted a recommendation if 80% consensus was achieved among at least 75% of panel members. We developed best practice statements as ungraded strong recommendations in adherence with strict conditions.
We report 29 recommendations on the management acute or ACLF in the ICU, related to five groups (cardiovascular, hematology, pulmonary, renal, and endocrine). Overall, six were strong recommendations, 19 were conditional recommendations, four were best practice statements, and in two instances, a recommendation was not issued because due to insufficient evidence. We discuss the abbreviated rationale for the six strong recommendations. The full recommendations and complete rationales can be found in the main article published in critical care medicine.