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

ARTICLE HIGHLIGHTS

Research background

The background of the study lies in the physiological response of sepsis, characterized by a dysregulated inflammatory reaction to infection, which can progress to organ failure and death. Cirrhotic patients are particularly susceptible to sepsis-induced organ failure and have higher mortality rates. The imbalance of cytokine response, known as a "cytokine storm," plays a significant role in the worsening of liver function and the development of organ/system failure in severe sepsis. The severity of sepsis in cirrhotic patients is associated with increased production of proinflammatory cytokines. Additionally, cirrhotic patients with severe sepsis can experience complications such as shock, acute lung injury, coagulopathy, renal failure, or hepatic encephalopathy. Understanding the background and significance of sepsis in cirrhosis is crucial for effective management and improved outcomes.

Research motivation

The motivation behind this research is to address the impact of sepsis in cirrhotic patients and the associated challenges in managing this complex condition. Sepsis is a major cause of admission to intensive care units (ICUs), and its outcomes are worse in patients with comorbidities like cirrhosis. Organ dysfunction in sepsis, measured by the Sequential Organ Failure Assessment (SOFA) score, including liver failure, is linked to higher mortality rates. Defining sepsis and septic shock accurately remains challenging. Given the high mortality and complexity of sepsis in cirrhosis, understanding the key problems and finding effective solutions is crucial. Solving these problems not only improves patient outcomes but also contributes to future research in this field by providing insights into personalized interventions, risk stratification, and resource allocation.

Research objectives

The main objectives of this study are to determine the optimal management of sepsis in cirrhotic patients admitted to the ICU and to explore strategies for improving outcomes in this population. Realizing these objectives has significant implications for future research in this field. By identifying effective management approaches, personalized interventions can be developed to address the specific needs of cirrhotic patients with sepsis. Furthermore, understanding the impact of different interventions on mortality and organ failure rates provides valuable insights for risk stratification and resource allocation. The successful realization of these objectives contributes to the advancement of knowledge and practices in managing sepsis in cirrhotic patients, ultimately improving patient care and outcomes in this challenging clinical scenario.

Research methods

This study utilized a systematic review methodology following the PRISMA-P protocol to investigate the management of sepsis in cirrhotic patients admitted to the ICU. The inclusion criteria comprised cirrhotic patients over 18 years old with sepsis in the ICU, and the analysis focused on sepsis management and prognosis in this population. English-language randomized controlled trials, retrospective cohort studies, and prospective cohort studies were considered. The outcomes assessed included survival, ICU length of stay, and overall prognosis. Searches were conducted on PubMed, Google Scholar, Embase, and Cochrane databases, with filtering based on titles and abstracts. Relevant papers underwent full-text analysis, and only those meeting the inclusion criteria were included. This systematic review offers valuable insights into sepsis management and prognosis in cirrhotic patients admitted to the ICU, utilizing a comprehensive approach to assess existing literature.

Research results

The study conducted a systematic review to investigate the management of sepsis in cirrhotic patients admitted to the ICU. The researchers selected 19 papers that met the inclusion criteria, focusing on survival and prognostic factors for this patient population. The findings indicated that albumin administration corrected hypotension in sepsis with cirrhosis, while corticosteroids improved hemodynamic status without affecting mortality. Procalcitonin was found to be helpful in diagnosing bacterial infections in cirrhotic patients, and vasopressors such as norepinephrine and terlipressin were recommended to maintain mean arterial pressure above specific thresholds. The prognosis was generally poor for cirrhotic patients with sepsis, especially for mechanically ventilated patients or those requiring vasopressors. The use of fluid resuscitation, particularly with human albumin, was recommended, and early antibiotic administration within the first hour showed improved outcomes. The qSOFA criteria were identified as a better predictor of adverse outcomes in sepsis, and echocardiography aided in diagnosing hyperdynamic syndrome. Liver transplantation was highlighted as the definitive treatment for cirrhotic patients. The study also mentioned the potential benefits and limitations of renal replacement therapy and liver support systems in sepsis management. Source control and glucose control were emphasized as essential aspects of sepsis management.

Research conclusions

The study proposes that the current therapeutic strategies for sepsis in cirrhosis patients, which are similar to the Surviving Sepsis Campaign guidelines for the general population, may not be sufficient in reducing mortality rates in this specific patient group. It highlights the need for further research and development of comprehensive management guidelines for sepsis in cirrhosis patients. The study suggests that the use of human albumin and norepinephrine, as well as combination therapy with terlipressin and norepinephrine, may be effective in correcting hypotension and improving outcomes in cirrhosis patients with sepsis. Additionally, it indicates that early administration of vasopressors could be more beneficial than aggressive fluid administration in this patient population. However, the use of corticosteroids did not show a decrease in mortality.

Research perspectives

Future research should focus on developing standardized management guidelines specifically tailored for sepsis in cirrhosis patients. These guidelines should encompass early detection of infection, appropriate antibiotic therapy, fluid resuscitation, vasopressor selection, and corticosteroid use. There is a need for larger, multicenter trials to validate the findings of existing studies and establish best practices for managing sepsis in cirrhosis patients. These studies should have larger sample sizes and address the limitations of previous research, such as single-center designs and missing data. Prognostic scores, such as SOFA, Model for End-Stage Liver Disease (MELD), and MELD-Na, should be further evaluated and incorporated into the management of sepsis in cirrhosis patients to identify high-risk individuals and guide treatment decisions. A multidisciplinary approach involving intensivists, hepatologists, infectious disease specialists, and other healthcare providers is essential for improving outcomes in septic cirrhotic patients. Collaboration and coordination among these specialties should be emphasized in future research and clinical practice.