From the Guidelines
Liver shock requires immediate medical attention in an intensive care setting, with treatment focusing on stabilizing hemodynamics using IV fluids and vasopressors, as recommended by the most recent guidance from 2024 1. The management of liver shock involves a multifaceted approach to address the underlying cause of the condition, whether it's sepsis, hemorrhage, or cardiac dysfunction.
- Key aspects of treatment include:
- Early baseline assessment of volume status, perfusion, and cardiovascular function in critically ill patients with cirrhosis 1.
- The use of bedside echocardiography to evaluate volume status and cardiac function in patients with cirrhosis and hypotension or shock 1.
- A judicious strategy for intravascular volume resuscitation utilizing hemodynamic monitoring tools, with balanced crystalloids (e.g., lactated Ringer's) and/or albumin (in select indications) recommended for fluid administration if resuscitation is required 1.
- Targeting a mean arterial pressure (MAP) of 65 mm Hg in patients with cirrhosis and septic shock, with ongoing assessment of end-organ perfusion 1.
- Vasopressor support is crucial, with norepinephrine recommended as the first-line vasopressor for patients with hypotension, alongside appropriate fluid resuscitation 1.
- Additional considerations include screening for adrenal insufficiency or an empiric trial of hydrocortisone for treatment of refractory shock requiring high-dose vasopressors in patients with cirrhosis 1. The approach to liver shock must be aggressive and prompt, given the potential for rapid progression to multi-organ failure if not adequately addressed.
From the Research
Definition and Causes of Liver Shock
- Liver shock, also known as hypoxic hepatitis or shock liver, is characterized by centrilobular liver cell necrosis and sharply increasing serum aminotransferase levels in a clinical setting of cardiac, circulatory, or respiratory failure 2.
- The main underlying conditions contributing to liver shock are low cardiac output and septic shock, although a multifactorial etiology is found in the majority of patients 2.
- Liver failure can occur in patients with or without underlying chronic liver disease and is associated with marked systemic inflammation and profound hemodynamic disturbances 3.
Clinical Management and Complications
- Patients with liver shock and vasopressor therapy have a significantly increased mortality risk in the medical intensive care unit population 2.
- Liver shock causes several complications such as spontaneous hypoglycemia, respiratory insufficiency due to the hepatopulmonary syndrome, and hyperammonemia 2.
- Early recognition of liver shock and its underlying diseases and subsequent initiation of therapy is of central prognostic importance 2.
- Fluid therapy should use crystalloids, and balanced salt solutions may limit the risk of hyperchloremic acidosis and subsequent adverse kidney events 3.
Intensive Care Unit Admission and Support Criteria
- Patients with cirrhosis frequently require admission to the intensive care unit (ICU) for organ support and management 4, 5.
- Common indications for ICU admission in patients with cirrhosis include sepsis, shock, acute gastrointestinal bleeding, and altered mentation 4.
- The Chronic Liver Failure Consortium ACLF score can be used to determine the need for ongoing intensive support or a palliative approach in patients with acute-on-chronic liver failure 5.