Emerging concepts in the care of patients with cirrhosis and septic shock

Abstract

Septic shock impacts approximately 6% of hospitalized patients with cirrhosis and is associated with high rates of morbidity and mortality. Although a number of landmark clinical trials have paved the way for incremental improvements in the diagnosis and management of septic shock in the general population, patients with cirrhosis have largely been excluded from these studies and critical knowledge gaps continue to impact the care of these individuals. In this review, we discuss nuances in the care of patients with cirrhosis and septic shock using a pathophysiology-based approach. We illustrate that septic shock may be challenging to diagnose in this population in the context of factors such as chronic hypotension, impaired lactate metabolism, and concomitant hepatic encephalopathy. Furthermore, we demonstrate that the application of routine interventions such as intravenous fluids, vasopressors, antibiotics, and steroids should be carefully considered among those with decompensated cirrhosis in light of hemodynamic, metabolic, hormonal, and immunologic disturbances. We propose that future research should include and characterize patients with cirrhosis in a systematic manner, and clinical practice guidelines may need to be refined accordingly.

Keywords: Cirrhosis; Septic shock; Intravenous fluids; Vasopressors; Antibiotics; Steroids

Core Tip: Septic shock is an important cause of morbidity and mortality among hospitalized patients with cirrhosis. In turn, the pathophysiology of cirrhosis impacts both the diagnosis and management of septic shock in meaningful ways. However, patients with cirrhosis have been traditionally underrepresented in clinical trials for septic shock, leading to critical knowledge gaps. The optimal care of these patients depends on achieving an understanding of the current limitations and implementing strategies for future research to address these shortcomings.