Chapter 9. Acute and Chronic Liver Failure in the ICU

Jesse B Hall, MD, FCCP
DOI: 10.1378/critcare.21.9
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  • Review the causes of acute liver failure and the management of patients with acute liver failure who may require liver transplantation.

  • Explain the pathophysiology of CNS dysfunction in both acute and chronic liver failure and the justification for invasive intracranial pressure monitoring.

  • Describe complications seen in the early postoperative period after liver transplantation.

  • Describe the causes of acute deterioration in patients with cirrhosis and how stabilization can be achieved early in the ICU course.


Patients with acute liver failure (ALF) or chronic liver failure (CLF) may require care in the ICU. Patients with ALF often require ICU care because of associated encephalopathy and cerebral edema, and they may require invasive monitoring of intracranial pressure to guide therapies to reverse elevated intracranial pressure and determine prognosis. In addition to supportive treatment and guided therapy to reverse causes of liver injury, the most severely ill patients with ALF often require simultaneous evaluation for liver transplantation. Accordingly, the critical care physician must be familiar with pretransplantation evaluation and transplant complications that may be encountered in the ICU. Patients with CLF, which is invariably related to underlying cirrhosis, often require ICU care for acute deteriorations related most often to infection, portosystemic encephalopathy (PSE), or GI hemorrhage. These patients may also be under consideration for liver transplantation but most frequently the goals of ICU care are to reverse their acute condition so they may be optimized for transplantation at some point in the future, if appropriate. For a patient with ALF or CLF, the critical care physician functions within the nexus of colleagues from hepatology, GI endoscopy, transplant medicine, surgery, and interventional radiology and will often need to coordinate these subspecialists to optimize care of the patient.


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