Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Apr 27, 2023; 15(4): 497-514
Published online Apr 27, 2023. doi: 10.4254/wjh.v15.i4.497
Emerging concepts in the care of patients with cirrhosis and septic shock
Jose Victor Jimenez, Guadalupe Garcia-Tsao, Saad Saffo
Jose Victor Jimenez, Guadalupe Garcia-Tsao, Saad Saffo, Section of Digestive Diseases, Yale School of Medicine, New Haven, CT 06520, United States
Author contributions: Jimenez J, Garcia-Tsao G, and Saffo S reviewed the literature and drafted the manuscript.
Conflict-of-interest statement: All the authors have no conflicts of interest to report.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Saad Saffo, MD, Academic Fellow, Section of Digestive Diseases, Yale School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, United States.
Received: December 28, 2022
Peer-review started: December 28, 2022
First decision: January 5, 2023
Revised: January 19, 2023
Accepted: March 23, 2023
Article in press: March 23, 2023
Published online: April 27, 2023

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.