What is the recommended blood pressure target for a patient with cirrhosis?

Blood Pressure Management in Cirrhosis

For patients with cirrhosis, a target mean arterial pressure (MAP) of 65 mmHg is recommended to maintain adequate organ perfusion while avoiding complications of portal hypertension. 1

Rationale for Blood Pressure Targets

• A retrospective observational study of 273 critically ill patients with cirrhosis reported increased ICU mortality when MAP fell below 65 mmHg, supporting the recommendation to maintain MAP >65 mmHg as an early goal in these patients 1

• Patients with cirrhosis typically have lower baseline blood pressure due to splanchnic vasodilation and decreased systemic vascular resistance, making appropriate BP targets crucial 2

• Recent research has identified that an outpatient MAP of 82 mmHg was most associated with better outcomes, suggesting this may be an optimal target for stable cirrhotic patients not in acute decompensation 3

Individualized Assessment Considerations

• Blood pressure management should include frequent assessment of end-organ perfusion markers including:

  • Mental status
  • Capillary refill
  • Urine output
  • Extremity perfusion
  • Lactate levels
  • Central venous oxygen saturation
  • End-organ function 1

• Bedside echocardiography is useful to evaluate volume status and cardiac function in patients with cirrhosis and hypotension or shock 1

• Invasive hemodynamic monitoring (arterial and central venous catheter) may be needed for adequate assessment of cardiac function and titration of vasopressors and fluid resuscitation in critically ill patients 1

Management of Hypotension in Cirrhosis

• For fluid resuscitation, balanced crystalloids (e.g., lactated Ringer's) and/or albumin (for select indications) are recommended 1

• Norepinephrine (0.01–0.5 μg/kg/min) is recommended as the first-line vasopressor to maintain adequate organ perfusion pressure 1

• Vasopressin is recommended as a second-line agent when increasing doses of norepinephrine are required 1

• In refractory shock requiring high-dose vasopressors, consider screening for adrenal insufficiency or an empiric trial of hydrocortisone 50 mg IV q6h or 200-mg infusion for 7 days 1

Special Considerations for Non-Selective Beta Blockers (NSBBs)

• In patients with refractory ascites or spontaneous bacterial peritonitis (SBP) with severe circulatory dysfunction (systolic blood pressure <90 mmHg, serum sodium <130 mEq/L, or hepatorenal syndrome), the dose of NSBBs should be decreased or the drug temporarily held 1

• High doses of NSBBs (over 160 mg/day of propranolol or over 80 mg/day of nadolol) should be avoided in patients with refractory ascites or SBP 1

• NSBBs may be reintroduced if circulatory dysfunction improves 1

Prognostic Implications of Blood Pressure

• Lower mean arterial pressure is associated with poor prognosis in cirrhosis, with studies showing decreased survival in patients with systolic BP <90 mmHg 2

• Recent research demonstrates that outpatient MAP is associated with important outcomes including:

  • Stage 2 acute kidney injury (adjusted HR 0.88 per 10 mmHg increase in MAP)
  • 5-point increase in MELD-Na score (adjusted HR 0.91 per 10 mmHg increase)
  • Waitlist mortality (adjusted HR 0.89 per 10 mmHg increase) 3

• Maintaining adequate blood pressure is critical for preventing hepatorenal syndrome, which has a median survival of less than 2 weeks 4

Monitoring and Adjustment

• Early baseline assessment of volume status, perfusion, and cardiovascular function should be performed in all critically ill patients with cirrhosis 1

• For patients with bleeding varices, a restrictive packed red blood cell transfusion strategy (transfusion when hemoglobin <7 g/dL with target 7-9 g/dL) improves survival in Child-Pugh A and B patients 1

• Avoid fluid overload which may exacerbate portal pressure, impair clot formation, and increase the risk of further bleeding 1