What is the management of hypotension in liver cirrhosis?

From the Guidelines

Hypotension management in liver cirrhosis involves a judicious strategy for intravascular volume resuscitation and the use of vasopressors. The initial approach should include early baseline assessment of volume status, perfusion, and cardiovascular function, as well as bedside echocardiography to evaluate volume status and cardiac function 1.

Key Management Strategies

• Intravascular volume resuscitation: Balanced crystalloids (e.g., lactated ringers) and/or albumin (select indications) are recommended for fluid administration if resuscitation is required 1.
• Vasopressor use: Norepinephrine is recommended as the first vasopressor for patients with hypotension, with vasopressin as a second-line agent when increasing doses of norepinephrine are required 1.
• Target MAP: A target mean arterial pressure (MAP) of 65 mm Hg is recommended in patients with cirrhosis and septic shock, with ongoing assessment of end-organ perfusion 1.

Additional Considerations

• Adrenal insufficiency: Consider screening for adrenal insufficiency or an empiric trial of hydrocortisone 50 mg i.v. q6h or 200-mg infusion for 7 days or until ICU discharge for treatment of refractory shock requiring high-dose vasopressors in patients with cirrhosis 1.
• Albumin administration: Albumin administration is recommended in select indications, such as large-volume paracentesis, paracentesis-induced circulatory dysfunction, spontaneous bacterial peritonitis, and hepatorenal syndrome 1.

From the Research

Management of Hypotension in Liver Cirrhosis

The management of hypotension in liver cirrhosis is a complex process that requires individualized management protocols to optimize patient outcomes 2.

Causes of Hypotension

Hypotension in liver cirrhosis can be caused by multifactorial reasons, including:

• A hyperdynamic state with increased cardiac index (CI) and low systemic vascular resistance (SVR) due to portal hypertension 2
• The use of beta-blocker or diuretic therapy 2
• Severe sepsis 2, 3, 4, 5
• Microvascular alterations in the liver, systemic inflammation, activation of renin-angiotensin-aldosterone system, and vasodilatation due to endothelial dysfunction 2

Assessment and Monitoring

Haemodynamic assessment includes:

• Measuring inferior vena cava indices, cardiac output (CO), and SVR using point-of-care ultrasound (POCUS) 2
• Arterial waveform analysis, pulmonary artery pressures, and lactate clearance to guide fluid resuscitation 2
• Monitoring tools such as echocardiography for bedside assessment of fluid status and responsiveness 4

Fluid Resuscitation

Fluid resuscitation in patients with cirrhosis and sepsis-induced hypotension is typically needed, but the choice of fluid is unclear 3, 4, 5.

• 5% human albumin has been shown to be superior to normal saline in reversing sepsis-induced hypotension 3
• 20% albumin has been shown to lead to a faster improvement in hemodynamics and lactate clearance than plasmalyte, but is associated with more pulmonary complications 5
• Large volumes of saline should be avoided in patients with cirrhosis 4

Vasopressor Use

Vasopressors such as norepinephrine may be used in patients with cirrhosis and sepsis-induced hypotension who are not responsive to fluid resuscitation 4.

• The role of terlipressin in this context needs to be clarified 4

Determinants of Blood Pressure

Determinants of 24-h arterial blood pressure in patients with cirrhosis include:

• A high post-sinusoidal resistance, a low plasma volume, a short central circulation time, and the presence of ascites 6
• A low intra-arterial blood pressure is determined by a low serum sodium, a low haemoglobin, and a high cardiac output 6