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. Author manuscript; available in PMC: 2023 Oct 15.
Published in final edited form as: Semin Liver Dis. 2022 Aug 24;42(3):362–378. doi: 10.1055/s-0042-1755274

Table 4.

ICU management

1. Neurologic
Abrupt deterioration in mental status?
 Yes: Head CT to look for intracranial hemorrhage
Serum sodium < 145 mMol/L?
 Yes → Consider using hypertonic saline for prophylaxis of intracranial hypertension to maintain serum Na between 145–155 mMol/L; carefully monitor rate of Na rise; discuss serum Na goal with health care team if patient on CRRT
Intubated, agitated or in pain?
 No → Avoid sedating medications (benzodiazepines, narcotics, central-acting anti-emetics)
 Yes → Use propofol and/or fentanyl
Spontaneous hypothermia (34–37°C)?
 Yes → Do not warm patient
Encephalopathy grade III/IV?
 Yes → Consider mannitol 0.25–1.0 g/kg IV q6 hours if serum osmolality < 320 mOsm/L or hypertonic saline boluses for treatment of suspected intracranial hypertension
  Yes → Consider intracranial pressure monitoring
 ■ Goal intracranial pressure < 25 mm Hg
  ■ Goal cerebral perfusion pressure 50–80 mm Hg
2. Pulmonary
Encephalopathy grade III/IV?
 Yes → Intubate; prefer low tidal volume ventilation to avoid acute lung injury
Intubated and spontaneously hyperventilating?
 Yes → Do not correct ventilation
3. Infectious disease
(1) Progression of encephalopathy or grade III/IV or (2) SIRS or (3) clinical deterioration or (4) patient listed for transplant? Surveillance cultures daily
 Yes/positive surveillance culture → Consider broad-spectrum antibiotics
4. Cardiovascular
Mean arterial pressure (MAP) < 75 despite volume repletion AND encephalopathy grade III/IV?
 Yes → Begin vasopressors (prefer norepinephrine over epinephrine or vasopressin)
 Yes → Consider trial of hydrocortisone
5. Renal
1) Oliguria or (2) rise in creatinine > 0.3 mg/dL or (3) ammonia > 150 μM or (4) volume overload or (5) established/suspected intracranial hypertension?
 No → Consider renal consultation/early hemodialysis
 Yes → Initiate CRRT (CRRT preferred over intermittent HD even if hemodynamically stable)
6. Hematology
Clinically significant bleeding?
 No → Do not correct INR
 Yes → Correct thrombocytopenia, hypofibrinogenemia and coagulopathy
Planned invasive procedure?
 No → Do not correct INR, if possible upon consultation with intensivists/radiologists/neurosurgeons
 Yes → Correct thrombocytopenia and hypofibrinogenemia (INR does not predict bleeding risk in patients with ALF)
7. Endocrine
Glucose < 80 mg/dL?
 Yes → Dextrose
Glucose > 180 mg/dL?
 Yes → Insulin
8. Gastrointestinal
Enteral feeding possible (PO or NG)?
 Yes → Begin as early as possible if no evidence of gastroparesis
9. Early transplant evaluation
Encephalopathy?
 Yes → Consult transplant center/transplant hepatologist early
Potential liver transplant candidate?
 Yes → Begin transplant evaluation per center protocol
All criteria for Status IA listing met?
All 3 of following criteria must be met:
 

  1. Onset of encephalopathy within 8 weeks of first symptoms of liver disease

  2. In the ICU

  3. (a) INR > 2 or (b) intubated or (b) on CRRT

  Yes→ Consider listing, in consultation with transplant team

Abbreviations: ALF, acute liver failure; CRRT, continuous renal replacement therapy; CT, computed tomography; HD, hemodialysis; ICU, intensive care unit; INR, international normalized ratio; IV, intravenous; Na, sodium; NG, nasogastric; PO, per oral; SIRS, systemic inflammatory response syndrome.

Note: Items to be checked on admission and daily.