Patients with end-stage liver disease (ESLD) can develop a number of complications that lead to, or complicate, critical illness.
Regarding the cardiovascular system, ESLD patients can develop:
Hyperdynamic vasodilated cardiovasculature: low baseline blood pressure and high cardiac output
"Cirrhotic cardiomyopathy": impaired systolic response to stress or altered diastolic relaxation
Autonomic dysfunction: reduced responsiveness to vasoconstrictors
ESLD patients also tend to have a normal or near-normal lactate at baseline, despite lactate being cleared more slowly.
When managing the critically ill patient with ESLD, look for signs of heart failure, expect an abnormal response to vasopressors, think about steroids for persistent shock, and don't ascribe an elevated lactate simply to impaired hepatic clearance.
References
Al-Khafaji A, Huang DT. Critical care management of patients with end-stage liver disease. Crit Care Med 2011; 39:1157-66.
