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The frequency of liver diseases in the intensive care unit has increased significantly in recent years and is now observed in up to 20% of critically ill patients. The occurrence of liver disease is associated with significantly increased morbidity and mortality. Two groups of liver diseases in the intensive care unit can be distinguished. First, the group of "primary hepatic dysfunctions", which includes primary acute liver failure as well as acute-on-chronic liver failure in patients with pre-existing liver cirrhosis. The second group of "secondary or acquired liver diseases" includes cholestatic liver diseases, as well as hypoxic liver injury and mixed forms, as well as other rarer liver diseases. Due to the diversity of liver diseases and the very different triggers, sufficient knowledge of the underlying changes (including hemodynamic changes, inflammatory states or drug-related) is essential. Early recognition, diagnosis, and treatment of the underlying disease are essential for all liver dysfunction in critically ill patients in the intensive care unit. This review article aims to take a closer look at liver diseases in the intensive care unit and provides insight into diagnostics and treatment options., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Gastrointestinal (GI) bleeding is one of the most common complications associated with the use of direct oral anticoagulants (DOAC). Clear algorithms exist for the emergency measures in (suspected) GI bleeding, including assessing the medication history regarding anti-platelet drugs and anticoagulants as well as simple coagulation tests during pre-endoscopic management. Platelet transfusions, fresh frozen plasma (FFP), or prothrombin complex concentrate (4F-PCC) are commonly used for optimizing the coagulation status. For severe bleeding under the thrombin inhibitor dabigatran, idarucizumab is available, and for bleeding under the factor Xa inhibitors rivaroxaban or apixaban, andexanet alfa is available as specific antidotes for DOAC antagonization. These antidotes represent emergency drugs that are typically used only after performing guideline-compliant multimodal measures including emergency endoscopy. Antagonization of oral anticoagulants should be considered for severe gastrointestinal bleeding in the following situations: (1) refractory hemorrhagic shock, (2) endoscopically unstoppable bleeding, or (3) nonavoidable delays until emergency endoscopy for life-threatening bleeding. After successful (endoscopic) hemostasis, anticoagulation (DOACs, vitamin K antagonist, heparin) should be resumed timely (i.e. usually within a week), taking into account individual bleeding and thromboembolic risk., Competing Interests: Dieses Manuskript fasst die wesentlichen Diskussionspunkte eines interdisziplinären Expertentreffens im Juli 2022 mit Vertreter*innen aus der Gastroenterologie, Intensivmedizin und Hämostaseologie zusammen, in dem die Bedeutung und mögliche Einsatzgebiete von spezifischen Antidots zur Antagonisierung der neuen/direkten orale Antikoagulantien (DOAK) bei schweren und lebensbedrohlichen gastrointestinalen (GI)-Blutungen diskutiert und herausgearbeitet wurde. Dieses Expertentreffen wurde durch die Fa. AstraZeneca (damals Alexion) finanziell unterstützt., (Thieme. All rights reserved.)

Bleedings are frequent and clinically important complications in critically ill patients in the intensive care unit, and-depending on location and intensity-are associated with high morbidity and mortality. The clinical impact of different bleeding entities is affected by the location (e.g. intracerebral bleedings), the severity (e.g. fulminant variceal bleeding) and the incidence (e.g. gastrointestinal bleeding) of the respective bleeding type. Therapy varies among bleeding entities, but consists of stabilization of the patient, control of the bleeding, and prevention of complications. This review describes relevant therapeutic aspects of selected bleeding complications in critically ill patients., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Acute abdomen is a common and sometimes dramatic clinical condition, which can be fatal if diagnosis is not made in time. A large number of diseases can cause an acute abdomen which makes a targeted and rapid diagnostic approach utterly important. The initial diagnostic approach is based on the clinical assessment (including medical history and physical examination) which allows doctors to quickly establish a suspected diagnosis with a relatively high sensitivity but a rather low specificity. Further diagnostics, including laboratory markers, imaging and - if necessary - interventional diagnostics should be initiated quickly after the first clinical assessment in order to confirm the suspected diagnosis or to further classify unclear cases. The clinical assessment is the leading diagnostic tool that determines further diagnostic approaches for patients with an acute abdomen and thus enables adequate and timely therapy., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Acute liver failure (ALF) is a rare condition with fatal outcome. Characteristic is rapid onset of liver damage without preexisting liver diseases, including hepatic encephalopathy and coagulopathy. Early and correct diagnosis is essential for further management of patients, since diagnosis impacts therapy choice. Survival of patients with ALF has improved dramatically due to advances in critical care medicine and the use of liver transplantation., (© Springer-Verlag GmbH Austria, ein Teil von Springer Nature 2018.)

Acute-on-chronic liver failure (ACLF) is an emerging clinical syndrome in patients with underlying liver disease that is usually triggered by one or multiple insults and characterized by progressive hepatic and nonhepatic organ failure, a significant risk of infections, and high short-term mortality rates. Despite our incomplete understanding of the underlying pathophysiology, ACLF requires timely diagnostic and therapeutic measures aiming at the identification and elimination of causative factors as well as the prevention of complications to improve the prognosis of affected patients.

Liver-lung interactions are common in daily clinical practice. However, frequently they are not the focus of clinical attention. For example, 10% of patients with acute-on-chronic liver failure and more than 30% of patients with advanced stages of acute-on-chronic liver failure suffer from respiratory failure. Conversely, up to 20% of critically ill patients develop secondary liver failure as a consequence of cardiopulmonary diseases or sepsis during their stay in the intensive care unit. This article provides an overview of clinically relevant liver-lung interactions, consecutively acquired pulmonary and hepatic diseases and the therapeutic implications.

Severe hyperlactaemia in intensive care patients is most often due to underlying sepsis or septic, cardiogenic or haemorrhagic shock. Hyperlactaemia is an independent predictor of death in various groups of critically ill patients. With serum lactate values > 10 mmol/l 80 % of the patients die in intensive care, and if the severe lactic acidosis persists for 48 hours, all patients die. Increased lactate levels require immediate diagnostic work-up and classification. The new sepsis definition requires a serum lactate > 2 mmol/l for septic shock with adequate volume substitution and vasopressor administration in order to achieve a mean arterial pressure in persistent hypotension ≥ 65 mmHg. The 1-hour bundle of the Surviving Sepsis Campaign published in 2018 recommends as a first measure the determination of the lactate serum concentrations, and increased values should be closely monitored. In addition, blood culture sampling, broad-spectrum antibiotics, fluid resuscitation and vasopressor administration are recommended within the first hour. Large amounts of crystalloids should be given for increased lactate levels (≥ 4 mmol/l) and refractory hypotension, the administration of fluids can be adjusted according to lactate clearance. Lactate metabolism is prolonged in patients with liver function impairment. Lactate levels on admission to intensive care are significantly associated with the number of failing organs and mortality in patients with cirrhosis. 12-hour lactate clearance has a strong predictive prognosis for survival in patients with baseline lactate levels above 5 mmol/l, the latter remains an independent predictor for the severity of the underlying disease even after correction. The greater the decrease in lactate during the initial therapy, the better the outcome., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Alterations of the kidney function can be observed often in patients with liver diseases. Different mechanisms are leading to alterations in kidney funciton in these patients. New onset of kidney function alterations in patients with acute- or chronic liver disease often leads to acute kidney injury. This Review will inform you about the most importatant clinical interactions of the kidneys and the liver., Competing Interests: Interessenkonflikt: Fuhrmann: Forschungsunterstützung (Baxter), Vortragstätigkeiten (Baxter, Hepawash)Roedl: keine InteressenskonflikteJarczak: keine Interessenskonflikte, (© Georg Thieme Verlag KG Stuttgart · New York.)