Key messages

• Changes in hepatic intermediary metabolism and an acute phase protein response occur during sepsis. Hepatic dysfunction ranges from poor hepatic clearance of test drugs to frank hyperbilirubinemia and intrahepatic cholestasis.

• A wide range of causes of jaundice can occur during critical illness. Accurate diagnosis is essential.

• In the absence of direct involvement of the liver, there is an increasing prevalence of jaundice with increasing severity of illness.

• The prognostic significance of jaundice in a critically ill patient depends on the clinical context. It is of little significance during bacteremia, but denotes a poor prognosis during acute respiratory distress syndrome or multiple organ failure syndrome.

• In multiple organ failure syndrome the mechanism includes changes in sinusoidal blood flow due to plugging by activated leukocytes and platelets, vasoactive mediators including complement products, platelet activating factor, leukotrienes, cytokines, and nitric oxide, as well as direct metabolic effects such as those due to oxygen free radicals.

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