1/ @sccm released a new table for the recent guidelines for the mgmt of acute (ALF) and acute-on-chronic liver failure (ACLF) in the ICU:

Summary table: https://bit.ly/374BEz0 
Guidelines: https://bit.ly/343A1Q1 

A summary of the summary below, the few strong recs are starred.

2/ Cardiac:
Use norepinephrine as first-line vasopressor, add vasopressin and stress-dose steroids for refractory shock
Target a MAP of 65 mm Hg
Use albumin for resuscitation, esp. when serum albumin <3 mg/dL
Use invasive hemodynamic monitoring to guide therapy

3/ Hematologic:
Use viscoelastic testing (TEG/ROTEM) over INR/platelet/fibrinogen in those undergoing procedures
Use transfusion threshold of 7 mg/dL
Use LMWH over SCDs for VTE prophylaxis in ACLF
Use LMWH or VKA over conservative mgmt for portal vein thrombosis or PE

4/ Pulmonary:
Use low tidal volume strategy over high tidal volume strategy
Recommend against high PEEP (over low PEEP) in ARDS
Use high-flow oxygen over NIV for hypoxemia
Treat portopulmonary hypertension if mPAP>35 mm Hg

5/ Pulmonary (continued):
Use oxygen for hepatopulmonary syndrome
Use chest tubes with attempt at pleurodesis for hepatic hydrothorax if TIPS not an option or for palliation

6/ Renal:
Use vasopressors in patients with ACLF who develop HRS
Use early RRT in patients with ALF and AKI

Endocrine:
Target serum blood glucose 110-180 mg/dL

7/ GI
Use enteral nutrition rather than parenteral
Screen for drug-induced causes of liver failure, stop offending drugs
Adjust medications that undergo hepatic metabolism with the help of a clinical pharmacist

8/ Things to avoid:
Hydroxyethyl starch or gelatin solutions for fluid resuscitation
Eltrombopag for patients with ACLF and thrombocytopenia prior to procedures
A low protein goal

9/ And finally, insufficient evidence for:
Intraoperative RRT for patients who were receiving preoperative RRT
TIPS for refractory ascites in cirrhosis as a way to prevent HRS