UMEM Educational Pearls

Acute on Chronic Liver Failure

  • Patients with cirrhosis can comprise up to 5% of an ICU population.
  • Many of these patients will present to the ED, and be admitted to the ICU, for acute on chronic liver failure.
  • A few management pearls for these patients include:
    • Consider albumin in patients with hepatorenal syndrome, large-volume paracentesis (> 5 L), and SBP
    • Norepinephrine is the initial vasopressor of choice; target a MAP ≥ 60 mm Hg
    • The INR does not accurately reflect bleeding in these patients.  Use platelet count and fibrinogen.
    • There is no need to correct coagulation abnormalities prior to routine procedures (e.g., central venous catheterization)


Fuhrmann V, Whitehouse T, Wendon J. The ten tips to manage critically ill patients with acute-on-chronic liver failure. Intensive Care Med. 2018.