The patient with chronic liver disease presents a range of potential challenges when a severe intercurrent illness occurs or major surgery is required. Even well-compensated liver cirrhosis in high functioning patients renders such individuals vulnerable to a myriad of problems when physiological stressors occur. Severe acute liver failure is another clearly defined sydrome in which extremely rapid and complex multiple organ failure typically ensues. Whilst intensivists are familiar and adept with the management of other major organ failure, new acute liver failure or decompensated chronic liver disease is particularly difficult to manage due to the inherent breadth of roles that the liver has in maintaining health as well as the current lack of comprehensive support therapies other than organ transplantation. While effective artificial life-supports for severe respiratory, cardiac or renal failure are available in the intensive care setting, support for over liver failure is less straightforward. The failing liver inevitably and rapidly impact on every other organ system, necessitating a systematic and comprehensive approach when planning patient care.
As with any dynamic and complex disease process, management is optimised when major clinical problems are anticipated and the detrimental impact is mitigated by the timely application of effective interventions. For patients with severe acute liver failure, a knowledge of the cause, disease trajectory, severity of organ failure as well as early interventions to prevent cerebral oedema are likely to improve outcomes. Specific treatments such as temperature management, respiratory support, osmotherapy and blood purification may be readily applied and reduce the risk of poor outcomes. In the setting of decompensated chronic liver disease, identifying reversible causes of deterioration and proactively managing the resulting predictable problems will ensure the best chance for recovery or stabilisation until subsequent transplantation. The majority of patients can be effectively managed in non-transplant centres, however it is also essential to identify those patients for whom orthotopic liver transplantation is the best or only option for survival. Early discussion with a transplant centre may assist intensivists in deciding who should be transferred and guide the timing of retrieval.