Review article: Practical considerations for fluid resuscitation in cirrhosis

Summary Background Standard clinical methods of assessing volume and providing resuscitation are not always applicable to patients with advanced or decompensated cirrhosis. Despite this being well known from a clinical perspective, there remains relatively little evidence to guide clinicians though fluid management in patients with cirrhosis and, often, multi‐organ system dysfunction. Aims This review summarises the current understanding of the circulatory dysfunction in cirrhosis, modalities for assessing volume status, and considerations for fluid selection. It additionally provides a practical approach to fluid resuscitation. Methods We review current literature on cirrhosis pathophysiology in steady‐state and shock, clinical implications of fluid resuscitation, and strategies to assess intravascular volume. Literature reviewed here was identified by the authors through PubMed search and review of selected papers' references. Results Clinical management of resuscitation in advanced cirrhosis remains relatively stagnant. Although several trials have attempted to establish the superior resuscitative fluid, the lack of improvement in hard clinical outcomes leaves clinicians without clear guidance. Conclusions The absence of consistent evidence for fluid resuscitation in patients with cirrhosis limits our ability to produce a clearly evidence‐based protocol for fluid resuscitation in cirrhosis. However, we propose a preliminary practical guide to managing fluid resuscitation in patients with decompensated cirrhosis. Further studies are needed to develop and validate volume assessment tools in the specific context of cirrhosis, while randomised clinical trials of protocolized resuscitation may improve care of this patient population. Systematic review of evidence for selection of resuscitative fluids in hospitalized patients with cirrhosis, including a practical guide to volume assessment, resuscitative fluids, and endpoints in resuscitation.