Management of Hemostatic Disorders in Patients With Advanced Liver Disease Admitted to an Intensive Care Unit

•In patients with liver diseases, hemostatic balance is maintained.•Simultaneous changes in pro- and antihemostatic drivers explain hemostatic rebalance.•Hemostatic balance is even maintained in critically ill patients with liver disease.•Clinical consequences include a restrictive use of (prophylactic) procoagulants.•A proactive approach to prevention of thrombosis is also warranted.

Patients with liver diseases frequently acquire complex changes in their hemostatic system. Traditionally, bleeding complications in patients with liver disease were ascribed to these hemostatic changes, and liver diseases were considered as an acquired bleeding disorder. Nowadays, it is increasingly acknowledged that patients with liver diseases are in “hemostatic rebalance” due to a commensurate decline in pro- and anticoagulant drivers. Indeed, both thrombosis and bleeding may complicate liver disease. Such complications may be particularly worrisome in critically ill patients with liver disease. This review will outline knowns and unknowns in prediction, prevention, and treatment of bleeding and thrombosis in patients with liver disease admitted to an intensive care unit.