The liver in critical illness

The liver is in some ways the forgotten organ in intensive care practice. Very many more laboratory and clinical studies have investigated the role, function, and support of the lung, heart, brain, and kidney in critical illness than have studied the liver. Nevertheless, in the time of the Greek scholars, there was already acknowledgement of the role of the liver in non-hepatic diseases such as systemic sepsis, and an understanding that such involvement confers a poorer prognosis – hence the inclusion of the wisdom of Hippocrates in this compilation of classic papers. In the review article by Matuschak and Rinaldo, the reasons why liver dysfunction is associated with a poorer outcome in critical illness are explored, and the concept of the liver being a ‘driving force’ in multiple organ dysfunction is developed. In addition, jaundice without significant liver dysfunction is associated with left ventricular dysfunction, at least in the dog model developed by Professor Otto Better and his colleagues in Israel. This observation is relevant to the progressive resistance to inotropic and vasopressor agents in jaundiced critically ill patients.