Liver cirrhosis in the medical critical care patient

Critically ill cirrhotic patients are characterized by unique and complicated clinical scenarios related to some characteristic and clear-cut pathophysiological features of their chronic end-stage liver disease that challenge Intensive Care Unit (ICU) physicians with several management problems. This class of patients may require admission to the ICU because of decompensation of their pre-existing liver disease or due to medical problems independent of cirrhosis as pneumonia, trauma or surgery. Either way, it is acknowledged that, when feasible, without definitive treatment by way of liver transplantation, cirrhosis is an independent predictor of poor outcome in critically ill patients. In fact, cerebral, cardiopulmonary and kidney dysfunctions as well as portal vein hypertension, ascites and gastrointestinal bleeding can make the course of these patients very complicated and may further affect their outcome. Despite some improvement that was recently reported, patients with decompensated cirrhosis pose to ICU physicians several and, sometimes, dramatic dilemmas in terms of therapeutic strategies and efficacy of the treatments also due to the lack of large specific studies on this particular class of patients. This review will focus on kidney, cardiopulmonary and cerebral complications of severe cirrhosis as well as those related to portal hypertension and their management.