Fluid resuscitation in patients with cirrhosis and sepsis: A multidisciplinary perspective

Fluid resuscitation is typically needed in patients with cirrhosis, sepsis and hypotension. However, the complex circulatory changes associated with cirrhosis and the hyperdynamic state, characterised by increased splanchnic blood volume and relative central hypovolemia, complicate fluid administration and monitoring of fluid status. Patients with advanced cirrhosis require larger volumes of fluids to expand central blood volume and improve sepsis-induced organ hypoperfusion than patients without cirrhosis, which comes at the cost of a further increase in non-central blood volume. Monitoring tools and volume targets still need to be defined but echocardiography is promising for bedside assessment of fluid status and responsiveness. Large volumes of saline should be avoided in patients with cirrhosis. Experimental data suggest that independent of volume expansion, albumin is superior to crystalloids at controlling systemic inflammation and preventing acute kidney injury. However, while it is generally accepted that albumin plus antibiotics is superior to antibiotics alone in spontaneous bacterial peritonitis, evidence is lacking in patients with infections other than spontaneous bacterial peritonitis. Patients with advanced cirrhosis, sepsis and hypotension are less likely to be fluid responsive than those without cirrhosis and early initiation of vasopressors is recommended. While norepinephrine is the first-line option, the role of terlipressin needs to be clarified in this context.