From the Guidelines
Fluid resuscitation in septic patients with end-stage liver disease should be carefully managed with a judicious strategy utilizing hemodynamic monitoring tools, and balanced crystalloids (e.g., lactated Ringer's) and/or albumin are recommended for fluid administration if resuscitation is required, as stated in the most recent guidance from 2024 1.
Key Considerations
- Early baseline assessment of volume status, perfusion, and cardiovascular function should be performed in all critically ill patients with cirrhosis, as recommended by the 2024 guidance 1.
- Bedside echocardiography is useful to evaluate volume status and cardiac function in patients with cirrhosis and hypotension or shock, according to the 2024 guidance 1.
- A target mean arterial pressure (MAP) of 65 mm Hg should be considered in patients with cirrhosis and septic shock, with ongoing assessment of end-organ perfusion, as stated in the 2024 guidance 1.
Fluid Resuscitation Strategy
- Balanced crystalloids (e.g., lactated Ringer's) are recommended as the initial fluid of choice for resuscitation, as stated in the 2024 guidance 1.
- Albumin may be beneficial as an adjunct to crystalloids, particularly in patients with significant hypoalbuminemia, as suggested by the 2024 guidance 1.
- Fluid administration should be guided by hemodynamic monitoring tools, such as central venous pressure measurements and echocardiography, to avoid fluid overload and ensure adequate tissue perfusion, as recommended by the 2024 guidance 1.
Vasopressor Therapy
- Norepinephrine is recommended as the first-choice vasopressor for patients with hypotension, as stated in the 2024 guidance 1.
- Vasopressin may be added to norepinephrine as a second-line agent when increasing doses of norepinephrine are required, as suggested by the 2024 guidance 1.
From the Research
Fluid Resuscitation Strategy for Sepsis in ESLD Patients
- The recommended fluid resuscitation strategy for sepsis in patients with end-stage liver disease (ESLD) is not explicitly stated in the provided studies, but general guidelines for sepsis treatment can be applied.
- According to 2, the Surviving Sepsis Campaign recommends crystalloids as the main fluid in resuscitation, but the possibility of using balanced crystalloids or combining with albumin is still under debate.
- A study by 3 suggests that balanced crystalloids, rather than saline, should be used, and crystalloids are preferred over semisynthetic colloids.
- Research by 4 reviews the advantages and limitations of different fluid types, including crystalloids and colloids, but does not provide conclusive evidence to support one fluid over another.
- A retrospective cohort study by 5 found that failure to administer 30 mL/kg of crystalloid fluid within 3 hours of sepsis onset was associated with increased odds of mortality, but this study did not specifically address ESLD patients.
- A review by 6 summarizes the current state of evidence for IV fluid resuscitation in septic shock, suggesting that a large positive fluid balance is associated with worse outcomes, but acknowledges the uncertainty and variation in practice.
Considerations for ESLD Patients
- Patients with ESLD may be at risk for volume overload, and fluid resuscitation strategies should be tailored to individual patient needs 5.
- The use of fluid responsiveness measures to guide fluid management in sepsis is still limited by applicability to patient populations and uncertainty regarding the effect on clinical outcomes 3.
- Further research is needed to determine the optimal volume and composition of fluid resuscitation in sepsis, including the role of albumin and the effects of deresuscitation after septic shock 3.