Management of liver failure in general intensive care unit - 05/10/19

Doi : 10.1016/j.accpm.2019.06.014

C. Paugam-Burtz ^1,², E. Levesque ^3,⁴, A. Louvet ⁵, D. Thabut ⁶, R. Amathieu ^7,⁸, C. Bureau ^9,^10,¹¹, C. Camus ¹², G. Chanques ¹³, S. Faure ¹⁴, M. Ferrandière ¹⁵, C. Francoz ^16,¹⁷, A. Galbois ¹⁸, T. Gustot ^19,²⁰, C. Ichai ²¹, P. Ichai ^22,^23,²⁴, S. Jaber ²⁵, T. Lescot ²⁶, R. Moreau ^27,^28,^29,³⁰, S. Roullet ^31,³², F. Saliba ³³, T. Thévenot ³⁴, L. Velly ^35,³⁶, E. Weiss ^37,^38,^⁎
¹ Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP–HP Nord, Université de Paris, 92110 Clichy, France
² UMR_S1149, Centre de recherche sur l’inflammation, Inserm, Université de Paris, France
³ Department of Anaesthesiology and Critical Care, Henri-Mondor Hospital, Assistance Publique–Hôpitaux de Paris, 94010 Créteil, France
⁴ EA Dynamyc UPEC, ENVA Faculté de Médecine de Créteil, 94000 Créteil, France
⁵ Department of Digestive Diseases, Claude Huriez Hospital, 59037 Lille, France
⁶ Department of Hepathology, Pitié-Salpêtrière Hospital, Assistance publique–Hôpitaux de Paris, 75013 Paris, France
⁷ Université Paris 13–UFR SMBH–CNRS UMR 7244, Paris, France
⁸ Critical Care Department, Diaconesses Croix Saint Simon Hospital Group, 75020 Paris, France
⁹ Department of Hepathology, Purpan Hospital, Toulouse University Hospital, 31300 ToulouseFrance
¹⁰ Institut Cardiomet, Cardiovascular and Metabolic Department, Rangueil Hospital, TSA 50032, 31059 Toulouse cedex 9, France
¹¹ Paul Sabatier University, 31330 Toulouse, France
¹² Department of Infectious Diseases and Medical Resuscitation, Rennes University Hospital, 35000 Rennes, France
¹³ Department of Anaesthesia and Intensive Care, Saint Eloi Montpellier University Hospital, and PhyMedExp, University of Montpellier, INSERM, CNRS, 34295 Montpellier cedex 5, France
¹⁴ Department of Hepathology, Saint Eloi Montpellier University Hospital, 34090 Montpellier, France
¹⁵ Surgical Intensive Care Unit, Tours University Hospital, 37044 Tours cedex 9, France
¹⁶ Department of Hepathology, Beaujon Hospital, AP–HP, 92110 Clichy, France
¹⁷ UMR_S1149, Centre de recherche sur l’inflammation, INSERM and Paris Diderot University, 75013 Paris, France
¹⁸ Ramsay Générale de Santé, Claude Galien Private Hospital, Department of Polyvalent Resuscitation, 91480 Quincy-sous-Sénart, France
¹⁹ Department of Gastroenterology and Hepato-Pancreatology, Erasme Hospital, Route de Lennik, 808, 1070 Bruxelles, Belgium
²⁰ Laboratory of Experimental Gastroenterology, Faculté de Médecine, Université Libre de Bruxelles, avenue Franklin-Roosevelt, 50, 1050 Bruxelles, Belgium
²¹ University of Côte D’Azur, Nice University Hospital, Department of Polyvalent Resuscitation, Pasteur 2 Hospital, 06000 Nice, France
²² Hepato-Biliary Center, Paul-Brousse Hospital, AP–HP, Liver Intensive Care Unit, 94800 Villejuif, France
²³ INSERM, Unité 1193, Université Paris-Saclay, 94800 Villejuif, France
²⁴ DHU Hepatinov, 94800 Villejuif, France
²⁵ Department of Anaesthesia and Intensive Care, Saint Eloi Montpellier University Hospital, and PhyMedExp, University of Montpellier, INSERM, CNRS, 34295 Montpellier cedex 5, France
²⁶ Sorbonne Université, Department of Anesthesiology and Critical Care Medicine, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, ParisFrance
²⁷ Inserm, Université Paris Diderot, Centre de Recherche sur l’Inflammation (CRI), 75018 Paris, France
²⁸ Department of Hepatology, Beaujon Hospital, AP–HP, 92110 Clichy, France
²⁹ European Foundation for the study on chronic liver failure (EF Clif), Barcelona, Spain
³⁰ Institute for Liver and Biliary Sciences (ILBS), New Delhi, India
³¹ Anaesthesiology and Critical Care Department 1, Bordeaux University Hospital, 33000 Bordeaux, France
³² University of Bordeaux, INSERM U 1034, Biology of Cardiovascular Diseases, 33000 Bordeaux, France
³³ Hepato-Biliary Center, Paul Brousse Hospital, AP-HP, INSERM Unité 935 and Unité 1193, 94800 Villejuif, France
³⁴ Department of Hepatology and Digestive Critical Care, Department of Hepatology, Jean Minjoz University Hospital, 25030 BesançonFrance
³⁵ Aix Marseille University, CNRS, Institut de Neuroscience de la Timone (INT), 13005 Marseille, France
³⁶ Department of Anaesthesiology and Critical Care Medicine, University Hospital La Timone, 13005 Marseille, France
³⁷ Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP–HP Nord, University of Paris, France
³⁸ UMR_S1149, Centre de recherche sur l’inflammation, INSERM and University of Paris, Paris, France

^⁎Corresponding author at: Service d’anesthésie-réanimation, hôpital Beaujon, 100, boulevard du Général-Leclerc, 92110 Clichy, France.Service d’anesthésie-réanimation, hôpital Beaujon100, boulevard du Général-LeclercClichy92110France

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Saturday 05 October 2019
Cet article a été publié dans un numéro de la revue, cliquez ici pour y accéder

Abstract

Objective

To produce French guidelines on Management of Liver failure in general Intensive Care Unit (ICU).

Design

A consensus committee of 23 experts from the French Society of Anesthesiology and Critical Care Medicine (Société française d’anesthésie et de réanimation, SFAR) and the French Association for the Study of the Liver (Association française pour l’étude du foie, AFEF) was convened. A formal conflict-of-interest (COI) policy was developed at the start of the process and enforced throughout. The entire guideline process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Some recommendations were ungraded.

Methods

Two fields were defined: acute liver failure (ALF) and cirrhotic patients in general ICU. The panel focused on three questions with respect to ALF: (1) Which etiological examinations should be performed to reduce morbidity and mortality? (2) Which specific treatments should be initiated rapidly to reduce morbidity and mortality? (3) Which symptomatic treatment should be initiated rapidly to reduce morbidity and mortality? Seven questions concerning cirrhotic patients were addressed: (1) Which criteria should be used to guide ICU admission of cirrhotic patients in order to improve their prognosis? (2) Which specific management of kidney injury should be implemented to reduce morbidity and mortality in cirrhotic ICU patients? (3) Which specific measures to manage sepsis in order to reduce morbidity and mortality in cirrhotic ICU patients? (4) In which circumstances, human serum albumin should be administered to reduce morbidity and mortality in cirrhotic ICU patients? (5) How should digestive haemorrhage be treated in order to reduce morbidity and mortality in cirrhotic ICU patients? (6) How should haemostasis be managed in order to reduce morbidity and mortality in cirrhotic ICU patients? And (7) When should advice be obtained from an expert centre in order to reduce morbidity and mortality in cirrhotic ICU patients? Population, intervention, comparison and outcome (PICO) issues were reviewed and updated as required, and evidence profiles were generated. An analysis of the literature and recommendations was then performed in accordance with the GRADE® methodology.

Results

The SFAR/AFEF Guidelines panel produced 18 statements on liver failure in general ICU. After two rounds of debate and various amendments, a strong agreement was reached on 100% of the recommendations: six had a high level of evidence (Grade 1 ±), seven had a low level of evidence (Grade 2 ±) and six were expert judgments. Finally, no recommendation was provided with respect to one question.

Conclusions

Substantial agreement exists among experts regarding numerous strong recommendations on the optimum care of patients with liver failure in general ICU.

Le texte complet de cet article est disponible en PDF.

Keywords : Acute liver failure, Acute-on-chronic liver failure, Guidelines, Cirrhosis, Intensive care unit

Plan

Working groups

Experts’ coordinators

Experts

Introduction

Aim of the guidelines

Definitions

Methods

Results

First area. Acute liver failure

Question 1: In patients with acute liver failure, which etiological exams should be performed to reduce morbidity and mortality?

Rationale

Question 2: In patients with acute liver failure, which specific treatments should be initiated rapidly to reduce morbidity and mortality?

Rationale

Question 3: In patients with acute liver failure, which symptomatic treatment should be initiated to reduce morbidity and mortality?

Rationale

Second area. Cirrhotic ICU patients and acute-on-chronic liver failure

Question 4: In patients with cirrhosis, which criteria should be used to guide admission or non-admission to an ICU to improve their prognosis?

Rationale

Question 5: In patients with cirrhosis hospitalised in an ICU, which specific measures to manage acute kidney injury should be used to reduce morbidity and mortality?

Rationale

Question 6: In patients with cirrhosis hospitalised in the ICU, which specific management of sepsis should be used to reduce morbidity and mortality?

Rationale

Question 7: In patients with cirrhosis hospitalised in ICU, when concentrated albumin should be administered to reduce morbidity and mortality?

Rationale

Question 8: In patients with cirrhosis hospitalised in the ICU, which management of acute upper gastrointestinal bleeding should be initiated to reduce morbidity and mortality?

Rationale

Question 9: In patients with cirrhosis hospitalised in the ICU, which measures to manage haemostasis should be initiated to reduce morbidity and mortality?

Rationale

Question 10: In patients with cirrhosis hospitalised in the ICU, when should expert advice be obtained in order to reduce morbidity and mortality?

Rationale

Disclosure of interest

Funding

☆	Validated by the SFAR Council on June 21st, 2018.
☆☆	With the collaboration of the following societies: Société française d’anesthésie et de réanimation, Association française pour l’étude du foie.