- Patients with cirrhosis admitted to the ICU are at risk of death due not only to liver disease, but also due to the many complications to which such patients are at risk.
- Worsening encephalopathy and loss of the gag reflex are indications for elective intubation in order to forestall potentially catastrophic aspiration or respiratory arrest.
- Invasive procedures carry extra risk in cirrhotics. When a procedure must be performed, care should be taken to minimize the likelihood of hemorrhagic complications.
- Spontaneous bacterial peritonitis should be considered and excluded in all cirrhotics with fever, encephalopathy, abdominal pain, or sepsis.
- Neomycin and metronidazole are superior to lactulose for the treatment of hepatic encephalopathy.
- The MELD score is a reliable method for predicting 3-month mortality and is currently used to determine transplant status.
- Transplant candidates who are deteriorating from chronic liver disease or its complications should be transferred to a transplant center for management.
Liver disease in the ICU may be secondary to the acute illness of patients or a complication of chronic disease. The focus of this chapter is to outline issues in the care of those with severe chronic liver disease, namely cirrhosis. Patients with cirrhosis who are admitted to the ICU have a very high risk of death. This stems not only from the underlying liver disease, but also from the complications to which these patients are prone. This chapter discusses the etiology of cirrhosis, the pathophysiology that leads to the complexity in management, common complications of cirrhosis, and a systematic approach to management of the critically ill liver patient. Hospitalized cirrhotic patients are more likely to die or to develop sepsis and respiratory failure than similar patients without cirrhosis. Due to the wide variety of complications and disease manifestations experienced by cirrhotic patients in the intensive care unit, a multidisciplinary approach involving gastroenterologists, hepatologists, intensivists, and transplant physicians must be employed. Particular attention should be given to preventing infection, assuring adequate nutrition and airway protection, and aggressively treating established infection, ascites, electrolyte disturbances, coagulopathy, encephalopathy, and bleeding.
Patients with stable chronic liver disease may suffer from decompensation due to progression of the underlying liver disease or to a comorbid illness that overwhelms the reserve of the diseased liver. Decompensation may be characterized by acute deterioration of otherwise stable clinical parameters such as mental status, coagulation, or hemodynamics. These patients may deteriorate rapidly, and therefore should be monitored closely with a low threshold for transfer to the ICU. Indications for transfer to the ICU include hemodynamic instability, suspected sepsis, decline in mental status, and need for more intensive nursing care.
The etiology of cirrhosis can vary greatly (Table 84-1) yet the clinical manifestations and complications due to scarring and fibrosis are similar. Therefore the approach to treatment and management of the cirrhotic is similar no matter what the underlying basis of the liver disease.