Tom, one of my colleagues from the Critical Care Outreach Team and I discuss this paper and its findings reaching our own conclusions.

Deferring Arterial Catheterisation in Patients with Septic Shock.

We return to our 48-year-old patient: jaundiced, hypotensive, drowsy, and bleeding. In decompensated cirrhosis, every treatment targets a disrupted system — splanchnic vasodilation, portal hypertension, toxin accumulation, and renal hypoperfusion.

Although these patients look fluid overloaded, they are effectively hypovolaemic. Start with small aliquots of balanced crystalloid, avoiding 0.9% saline. In hepatorenal syndrome or tense ascites, 20% albumin is key — not just for volume expansion, but for circulatory and anti-inflammatory support.

Once volume is optimised, flow must be redirected. Terlipressin reverses splanchnic vasodilation, reduces portal pressure, and improves renal perfusion. If contraindicated, noradrenaline targeting a MAP ≥65 mmHg is an effective alternative.

Variceal bleeding reflects portal hypertension, not missing clotting factors. Use restrictive transfusion, correct platelets and fibrinogen selectively, start antibiotics early, and proceed to endoscopic banding once haemodynamically stable. Avoid blanket correction of INR — treat bleeding, not numbers.

Hepatic encephalopathy management focuses on reversing precipitants and reducing ammonia with lactulose and rifaximin, while protecting the airway in advanced grades. Infection screening is essential — SBP and sepsis worsen vasodilation and renal failure, with albumin improving outcomes.

Renal dysfunction is functional, not structural. Albumin plus vasoconstrictors can restore perfusion. Nutrition is critical: early enteral feeding with adequate protein supports recovery and ammonia clearance.

Bottom line: cirrhosis care works when physiology drives every decision.

In this episode, I walk through the real-world critical care management of acute decompensated alcohol-related liver disease, using a high-risk ICU case to anchor the discussion. The focus is on understanding the underlying physiology—portal hypertension, rebalanced haemostasis, hepatic encephalopathy, infection, and hepatorenal syndrome—and translating that physiology into clear first-hour priorities at the bedside.

Listeners are guided through airway and circulatory decision-making, rational use of albumin, vasopressors, antibiotics, lactulose and rifaximin, and careful blood product transfusion, while avoiding common pitfalls such as reflexive FFP or over-resuscitation.

The episode emphasises early recognition of red flags, the central role of infection as a precipitant, and the interconnected nature of multi-organ failure in acute-on-chronic liver disease, all framed within pragmatic UK ICU practice.