Skip to Main Content




  • Portal hypertension, resulting from increased intrahepatic resistance to portal flow and increased portal inflow, marks the transition from compensated to decompensated cirrhosis.

  • The sequelae of portal hypertension affect each organ system, requiring multi-disciplinary management.

  • Grades III and IV hepatic encephalopathy require immediate ICU transfer and elective intubation for airway protection.

  • Pulmonary derangements resulting from portal hypertension may be severe and include hepatopulmonary syndrome, portopulmonary hypertension, and hepatic hydrothorax.

  • Hepatorenal syndrome is a diagnosis of exclusion and is characterized by renal impairment in the setting of advanced liver disease, circulatory dysfunction, and increased activity of the renin-angiotensin system.

  • SBP is a known precipitant of HRS, which is a cause of increased mortality in cirrhotic patients; therefore empiric antibiotic treatment is warranted in patients in whom the suspicion for SBP is high.

  • Aggressive intravenous resuscitation, airway protection, and early endoscopic management of cirrhotic patients presenting with suspected variceal bleed is critical.




Hepatic decompensation in the critical care setting can present in two distinct contexts, which include acute liver failure and acute on chronic liver failure. In this chapter, we discuss the critical care approach to acute on chronic liver failure. In the intensive care setting, severe cases of acute on chronic liver failure require a systematic multiorgan system approach to management in order to address hepatic and extrahepatic organ dysfunction. An optimization of hepatic and extrahepatic derangements, including cardiopulmonary, neurologic and renal dysfunction, is essential for the successful management of the critically ill cirrhotic patient.


The pathophysiology and sequelae of chronic liver disease warrant a unique approach to ICU management and treatment of disease. Namely, portal hypertension marks the transition from compensated to decompensated cirrhosis, resulting in life-threatening conditions including gastrointestinal variceal bleeding, hepatorenal syndrome, pulmonary complications, and hepatic encephalopathy.1


Portal hypertension in cirrhosis is a result of the combined effect of intrahepatic resistance to portal flow and increased portal inflow. The resistance to portal flow consists of both fixed and functional components. The fixed component occurs from sinusoidal fibrosis and compression by regenerative nodules. The functional component is secondary to vasoconstriction, resulting from both decreased intrahepatic nitric oxide and enhanced intrahepatic vasoconstrictor activity. The paradoxical decreased intrahepatic nitric oxide and overproduction of extrahepatic nitric oxide produces splanchnic vasodilation and increased portal inflow. Combined, the effects of the intrahepatic resistance to flow and increased portal inflow result in a portal hypertensive state.2 In addition, the pathologic splanchnic vasodilation results in a shunting of the cardiac output to the splanchnic circulation, and an associated decrease in effective systemic arterial blood volume perfusing other organ systems. These hemodynamic derangements in the splanchnic and systemic circulation form the basis for current management strategies in decompensated cirrhosis. An organ-system-based review of the management of specific disease manifestations in acute on chronic liver failure follows.




Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.


About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.