Quality of Evidence (using GRADE) supporting the recommendations and within the DC Care Bundle and proposed minimum standards to audit adherence with the recommendations
| Recommendations | Quality of evidence | Minimum audit standard |
| Patients presenting with DC should have a full history, clinical examination and investigations to look for the cause of decompensation and the presenting features | Not graded | 100% |
| Patients should be screened for infection including urinalysis and urine culture, chest X-ray and blood cultures. | Moderate | 90% |
| For patients with clinically detectable ascites, an ascitic tap should be performed at the earliest opportunity to exclude spontaneous bacterial peritonitis (SBP). | Moderate | 90% |
| Patients should have an alcohol history documented. | High | 90% |
| For patients with ALD who continue to consume alcohol, parenteral thiamine and other B vitamins (eg, Pabrinex: two pairs of vials three times daily for 3 days or parenteral thiamine) should be given to treat thiamine deficiency and reduce the risk of alcohol-related brain injury (Wernicke’s encephalopathy or Korsakoff’s syndrome). | High | 90% |
| Patients who have symptoms of alcohol withdrawal or who are at high risk of alcohol withdrawal should be assessed with a validated tool such as the revised Clinical Institute Withdrawal Assessment–Alcohol scale or Glasgow Modified Assessment and Management of Alcohol tool and be treated with a symptom-triggered regimen of benzodiazepines. | High | 90% |
| SBP should be treated promptly with broad spectrum antibiotics according to hospital policy, with modifications according to culture results | High | 100% |
| Patients with SBP are at high risk of developing hepatorenal syndrome and should have intravenous albumin administered to prevent worsening of renal function (1.5 g/kg of 20% human albumin solution at diagnosis) | Moderate | 90% |
| Initial management of AKI should include suspension of all diuretics and nephrotoxic drugs, and assessment of intravascular volume. | Moderate | 90% |
| Patients with AKI should be fluid-resuscitated with crystalloid, giving boluses of 250 mL with regular volume status reassessment aiming to achieve euvolaemia with a urine output of >0.5 mL/kg/hour based on dry weight. | Moderate | 90% |
| Terlipressin (2 mg stat then 1–2 mg four times a day; 1 mg if patients are <50 kg) is recommended as a first line agent in the management of acute variceal bleeding unless absolute or relative contraindications are found. | High | 80% |
| We recommend that patients with cirrhosis presenting with GI bleeding are treated with prophylactic antibiotics according to local protocol. | High | 90% |
| We recommend a restrictive transfusion target of 70–80 g/L in haemodynamically stable patients with upper GI bleeding. | High | 90% |
| In conscious patients with hepatic encephalopathy, oral lactulose should be administered. | Moderate | 90% |
| Given the potential increased risk of VTE and significant associated morbidity in patients with cirrhosis, we recommend thromboprophylaxis with LMWH for patients admitted with DC unless they have active bleeding. | Low | 90% |
AKI, acute kidney injury; ALD, alcohol-associated liver disease; DC, decompensated cirrhosis; GI, gastrointestinal ; GRADE, Grading of Recommendation Assessment Development and Evaluation; LMWH, low-molecular-weight heparin; VTE, venous thromboembolism.