Acute Liver Failure with Hypotension Not Responsive to Norepinephrine: Next-Step Management
Clinical Scenario
A patient with acute liver failure develops hypotension refractory to fluid resuscitation. Norepinephrine is initiated as the first-line vasopressor, yet haemodynamic targets remain out of reach. The question becomes: what is the next step when first-line vasopressor therapy is insufficient?
First-Line Therapy — Failure Condition
Initial vasopressor support with norepinephrine (first-line agent for hypotension refractory to fluid resuscitation) did not achieve the required goal:
Cerebral perfusion pressure of 60–80 mm Hg was not maintained.
This failure to meet haemodynamic targets is the trigger for escalation to the next management step.
Next-Step Approach
When norepinephrine alone is insufficient, evidence-based guidance supports adding a secondary vasopressor agent. The full structured protocol specifies which agent, how it fits into the overall haemodynamic strategy, and the relevant considerations for its use in acute liver failure.
References
- DOI: 10.14309/ajg.0000000000002340
- In patients with ALF with hypotension not responsive to norepinephrine, we suggest adding vasopressin as a secondary agent.
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