Management of sepsis in a cirrhotic patient admitted to the intensive care unit: A systematic literature review

Table 3 Retrospective cohort studies

Ref.	Purpose	Type of study	Sample size	Conclusion	Setting
Guo et al[26]	Assessment of VCS parameter for evaluation of sepsis in cirrhotic patients	Retrospective analysis of prospective data	257 patients	Proposed management was collection of blood culture, white cell volume determination, procalcitonin, and interleukin -6, sCD163 laboratory tests. Conclusion VCS parameters have the potential to be used to evaluate and predict early infections in patients with cirrhosis, and VCS can increase sensitivity and specificity in the diagnosis of sepsis and cirrhosis patients	ICU
Villarreal et al[15]	Assessing the usefulness of procalcitonin for diagnosing infection in cirrhotic patients	Retrospective cohort study	66 patients of 255 admitted had procalcitonin tests. Patients with infection suspicion had a serum procalcitonin (PCT) test within the first 12 h	Septic patients with cirrhosis had elevated procalcitonin. As PCT has a sensitivity of 83% and specificity of 75% is an effective tool for diagnosing infection in patients with liver cirrhosis. Excellent tool for differentiating infectious disease in cirrhotic patients	ICU
Galbois et al[27]	Assess whether the mottling score and tissue oxygen saturation (StO2) may be used as early death predictors on cirrhotic patients with septic shock. Hemodynamic parameters at 6 h in patients with liver cirrhosis according to their survival status at 14 days	42 out of 46 patients admitted with cirrhosis and septic shock were analyzed		There is systemic vasodilation and increased mortality in cirrhosis patients with sepsis. Patients with increased mottling died, and those with decreased survived. Mottling score and knee StO2 measures 6 h after starting vasopressors are excellent predictors of 14-day mortality	ICU
Piccolo Serafim et al[14]	The study evaluates the use of steroids in a patient with septic shock and cirrhosis	A retrospective cohort study (2007-2017)	56 patients out of 179 admitted with septic shock received steroids during ICU	The use of steroids did not show significant differences in mortality. Vasopressor requirement and is not associated with decreased mortality	ICU
Chang et al[17]	aimed to determine whether septic patients with liver cirrhosis had worse survival than patients without liver cirrhosis	Retrospective cohort	776 patients, 64 had sepsis with cirrhosis, 712 sepsis without cirrhosis	Cirrhotic patients with sepsis had a poor outcome, and the survival of sepsis and cirrhosis after matching was not inferior to those without cirrhosis	ICU
Sauneuf et al[18]	Assess the use of albumin as an adjuvant to vasopressors in managing septic shock in cirrhotic patients	Retrospective cohort single center and observational overdone over 14 years studied done from 1997 to 2004 and 2005 to 2010	During the period 2005 to 2010, 42, cirrhotic patients with septic shock in ICU were included	In conclusion, the survival rate of septic shock in cirrhosis remains low, and current shock management could benefit cirrhotic patients. Treatment use is: Vasopressors used is norepinephrine, epinephrine, and dobutamine; mechanical ventilation was used in the case of ARDS, and a protective strategy with a low tidal volume of 6 m/kg of body weight, and the plateau was kept below 30 cmH2O, small -dose of corticosteroids (200 mg hydrocortisone per day, insulin therapy, The main sites of infections were: Pneumonia, spontaneous or secondary peritonitis, and urinary tract infection. There were gram-positive and negative. Septic shock represent a severe complication of cirrhosis with very low survival rates. Sepsis in a cirrhotic patient has a poor prognosis. Hydrocortisone did not reduce mortality and was associated with adverse effects such as shock relapse and gastrointestinal bleeding. Cirrhotic patients are commonly perceived as poor candidates for `ICU admission because of the very high mortality	ICU
Umgelter et al[21]	Assess the outcome of the continuous low dose of TP in a septic shock patient	Small cohort study	2004-2007: 12 patients, 8 males, and 4 females were included with sepsis due to spontaneous bacterial peritonitis, pneumonia, and cholangitis	TP is currently used in treating cirrhotic patients with hepatorenal syndrome and as an adjunct to NE in a cirrhotic patient with septic shock and kidney failure; TP dose 2 ug/kg if a patient was started NE in the first 24 h. 11 patients had RRT, TP increased SVR index and NE doses needed to obtain target MAP decreased while the CI remained stable. Despite hemodynamic improvement, 11 out of 12 patients died. The author concluded that TP was effective as a vasopressor in septic cirrhotic patients at a low dose in combination with NE, and there was no dramatic decrease in CI. TP has a role in the early treatment of septic shock, and the author recommends a controlled study with TP in a cirrhotic patient with sepsis	ICU
Durst et al[20]	The study aimed to evaluate the use of vasopressor in septic shock with cirrhosis and without cirrhosis	single-center, retrospective cohort, 18 years	122 patients included were 61 with cirrhosis and 61 non-cirrhosis with sepsis, and septic with cirrhosis		ICU
Maimone et al[12]	Compare the 20% albumin to plasmolytes in managing cirrhosis and sepsis in the intensive care unit	Retrospective cohort study	100 patients with cirrhosis and sepsis-induced hypotension		ICU
Bal et al[24]	The aim is to predict 50 days in hospital mortality in decomposed cirrhosis patients with SBP	A single-centre study prospective study	218 were admitted to ICU from 2013-2014 with cirrhosis and spontaneous bacterial peritonitis		ICU
Chebl et al[22]	Assess the outcome and mortality predictor of cirrhosis patients with sepsis	A single-center retrospective cohort study	200 patients	The study revealed an increased risk of sepsis in cirrhotic patients and sepsis-induced organ failure and related death in cirrhosis. The management of shock is to keep MAP above 65 mmgh with vasopressors; the aggressive fluid hydration may worsen the outcome as there is low oncotic pressure in a cirrhotic patient, which may lead to oedema with aggressive fluid hydration, so it is good to start with vasopressors early in the treatment of septic cirrhosis patients to avoid complications, a cirrhotic patient has higher lactate than the non-cirrhotic because of decreased lactate clearance by the liver	ICU
Chen et al[25]		A single-center, retrospective cohort study from 2015 to 2018	104 patients with cirrhosis and bacteremia were subdivided into afebrile (55) and febrile (49)	The cirrhotic patient is prone to infection. Cirrhotic patients with bacterial infections present with atypical manifestations such as normothermia. Scoring systems focused on organ dysfunction, such as quick sequential organ failure assessment (qSOFA) score or chronic liver failure sequential organ failure assessment (CLIF-SOFA) score, have better predictor ability	In the emergency department
Sasso et al[19]	Assess the prediction of mortality in a cirrhotic patient	Prospective cohort	113 patients mechanically ventilator cirrhotic from 2014-2018	Conclude that cirrhotic patients requiring mechanical ventilation have an extremely poor prognosis, and the vasopressor requirement was strongly a predictor of mortality in mechanical ventilation cirrhosis with sepsis	ICU
Fischer et al[12]	Assess the use of presepsin and resistin as markers of bacterial infections in cirrhotic patients with sepsis			Conclusion: Both presepsin and resistin may be reliable markers of bacterial infections in patients with decompensated liver cirrhosis and have similar diagnostic performance for bacterial infection and sepsis compared to C-reactive protein (CRP) and PCT. The best cut-off level of presepsin for diagnosis of sepsis was 1444 pg/mL. Conclusion PCT, CRP, Presepsin, and resistin had similar accuracy in diagnosing infection and sepsis in decompensated cirrhosis	ICU
Baudry et al[9]	Assess the prognosis of sepsis in cirrhotic patients	A Retrospective cohort study from 2002-2013	7644 patients were admitted, where 149 were		ICU

VCS: Value of volume conductivity and scattering; PCT: Procalcitonin; STO₂: Tissue oxygen saturation; ARDS: Acute respiratory distress syndrome; TP: Telipressin; NE: Norepinephrine; SVR: Systemic vascular resistance; RRT: Renal replacement therapy MAP: Mean arterial pressure; CI: Cardiac index, ATB: Antibiotic; MELD: Model for End-Stage Liver Disease; AKI: Acute kidney injury; SBP: Systolic blood pressure; qSOFA: Quick sequential organ failure assessment; ICU: Intensive care unit.