Outcomes of Acute Respiratory Distress Syndrome in Mechanically Ventilated Patients With Cirrhosis

Outcomes of critically ill patients with liver failure who require mechanical ventilation: A retrospective, single-center study

Background and Aims

Critically ill patients with liver failure have high mortality. Besides the management of organ-specific complications, liver transplantation constitutes a definitive treatment. However, clinicians may hesitate to introduce mechanical ventilation for patients on liver transplantation waitlists because of poor prognosis. This study investigated the outcomes of intensive care and ventilation support therapy effects in patients with liver failure.

Methods

This single-center study retrospectively enrolled 32 consecutive patients with liver failure who were admitted to the intensive care unit from January 2014 to December 2020. The medical records were reviewed and analyzed retrospectively for Acute Physiologic and Chronic Health Evaluation (APACHE)-II. The model for end-stage liver disease scores, 90-day mortality, and survival was assessed using the Kaplan-Meier method.

Results

The average patient age was 45.5 ± 20.1 years, and 53% of patients were women. On intensive care unit admission, APACHE-II and model for end-stage liver disease scores were 20 and 28, respectively. Among 13 patients considered for liver transplantation, 4 received transplants. Thirteen patients (40.6%) were intubated and mechanically ventilated in the intensive care unit. The 90-day mortality rate of patients with and without mechanical ventilation in the intensive care unit (13, 61.5% vs. 19, 47.4%, p = 0.4905) was similar. APACHE-II score >21 was an independent predictor of mechanical ventilation requirement in patients with liver failure during intensive care unit stay.

Conclusion

Although critically ill patients with liver failure are at risk of multiorgan failure with poor outcomes, mechanical ventilation did not negatively affect the 90-day mortality or performance rates of liver transplantation. Clinicians should consider mechanical ventilation-based life support in critically ill patients with liver failure who are awaiting liver transplantation.

Clinical determinants of hospital mortality in liver failure: a comprehensive analysis of 62,717 patients

BACKGROUND

Liver failure (LF) is characterised by a loss of the synthetic and metabolic liver function and is associated with a high mortality. Large-scale data on recent developments and hospital mortality of LF in Germany are missing. A systematic analysis and careful interpretation of these datasets could help to optimise outcomes of LF.

METHODS

We used standardised hospital discharge data of the Federal Statistical Office to evaluate current trends, hospital mortality and factors associated with an unfavourable course of LF in Germany between 2010 and 2019.

RESULTS

A total of 62,717 hospitalised LF cases were identified. Annual LF frequency decreased from 6716 (2010) to 5855 (2019) cases and was higher among males (60.51%). Hospital mortality was 38.08% and significantly declined over the observation period. Mortality significantly correlated with patients' age and was highest among individuals with (sub)acute LF (47.5%). Multivariate regression analyses revealed pulmonary (ORARDS: 2.76, ORmechanical ventilation: 6.46) and renal complications (ORacute kidney failure: 2.04, ORhepatorenal syndrome: 2.92) and sepsis (OR: 1.92) as factors for increased mortality. Liver transplantation reduced mortality in patients with (sub)acute LF. Hospital mortality significantly decreased with the annual LF case volume and ranged from 47.46% to 29.87% in low- or high-case-volume hospitals, respectively.

CONCLUSIONS

Although incidence rates and hospital mortality of LF in Germany have constantly decreased, hospital mortality has remained at a very high level. We identified a number of variables associated with increased mortality that could help to improve framework conditions for the treatment of LF in the future.

Alcohol use disorder in the intensive care unit a highly morbid condition, but chemical dependency discussion improves outcomes

BACKGROUND

Alcohol use disorders (AUD) are common in patients admitted to intensive care units (ICU) and increase the risk for worse outcomes. In this study, we describe factors associated with patient mortality after ICU admission and the effect of chemical dependency (CD) counseling on outcomes in the year following ICU admission.

METHODS

We retrospectively reviewed patient demographics, hospital data, and documentation of CD counseling by medical providers for all ICU patients with AUD admitted to our institution between January 2017 and March 2019. Primary outcomes were in-hospital and 1-year mortality.

RESULTS

Of the 527 patients with AUD requiring ICU care, median age was 56 years (range, 18-86). Both in-hospital (12%) and 1-year mortality rates (27%) were high. Rural patients, comorbidities, older age, need for mechanical ventilation, and complications were associated with increased risk of in-hospital and 1-year mortality. CD counseling was documented for 73% of patients, and 50% of these patients accepted alcohol treatment or resources prior to discharge. CD evaluation and acceptance was associated with a significantly decreased rate of readmission for liver or alcohol-related issues (36% vs. 58%; odds ratio [OR], 0.41; 95% confidence interval [CI], 0.27-0.61) and 1-year mortality (7% vs. 19.5%; OR, 0.32; 95% CI, 0.16-0.64). CD evaluation alone, regardless of patient acceptance, was associated with a significantly decreased 1-year post-discharge mortality rate (12% vs. 23%; OR, 0.44; 95% CI, 0.25-0.77).

CONCLUSIONS

ICU patients with AUD had high in-hospital and 1-year mortality. CD evaluation, regardless of patient acceptance, was associated with a significant decrease in 1-year mortality.

The Impact of Chronic Medical Conditions on Mortality in Acute Respiratory Distress Syndrome

PURPOSE

To examine the impact of chronic comorbidities on mortality in Acute Respiratory Distress Syndrome (ARDS).

MATERIALS AND METHODS

Retrospective cohort study of adults with ARDS (ICD-10-CM code J80) from the National Inpatient Sample between January, 2016 and December, 2018. For the primary outcome of mortality, we conducted weighted logistic regression adjusting for factors identified on univariate analysis as potentially significant or differing between the two groups at baseline. We used negative binomial regression adjusting for the same comorbidities to identify risk factors for longer length of stay (LOS) among ARDS survivors.

RESULTS

After exclusions, 1046 records were analyzed (3355 ARDS survivors and 1875 non-survivors.) The comorbidities examined included hypertension, diabetes mellitus, obesity, hypothyroidism, alcohol and drug use, chronic kidney disease (CKD), cardiovascular disease, chronic liver disease, chronic pulmonary disease and malignancy. In multivariate analysis, we found that malignancy (OR 2.26, 95% CI 1.84-2.78, p < 0.001), cardiovascular disease (OR 1.54, 95% CI 1.23-1.92, p < 0.001), and CKD (OR 1.75, 95% CI 1.22-2.50, p  =  0.002) increased the risk of death. In interaction analyses, cardiovascular disease combined with either malignancy or CKD conferred higher odds of death compared to either risk factor alone.

CONCLUSIONS

The comorbidity of malignancy confers the most reliable risk of poor outcomes in ARDS with higher odds of hospital death and a simultaneous association with longer hospital LOS among survivors.

Factors affecting the outcomes in patients with acute respiratory distress syndrome in a tertiary care setting

Purpose

The clinical profile and factors affecting outcomes in acute respiratory distress syndrome (ARDS) from adequately sample-sized Indian studies are still lacking. We aimed to investigate the clinical profile, treatment pattern, outcomes; and to assess factors affecting non-recovery in ARDS patients.

Patients and methods

A retrospective observational study was conducted among adult ARDS patients admitted during five year period (January 2014-December 2018) in a South Indian tertiary care setting. The relevant data were collected from the medical records to the data collection form. The univariate and multivariate logistic regression analyses were conducted to identify the predictors of outcomes using SPSS v20.

Results

A total of 857 participants including 496 males and 361 females with a mean age of 46.86 ± 15.81 years were included in this study. Fever (70.9%), crepitation (58.3%), breathlessness (56.9%), and cough (45%) were the major clinical presentation. Hypertension (25.2%), kidney disease (23.8%), and diabetes (22.3%) were the major comorbidities; and sepsis (37.6%), pneumonia (33.3%), and septic shock (27.5%) were the major etiological factors observed. Antibiotics and steroids were administered to 97.9% and 52.3% of the population, respectively. The recovery rate was 47.49%. The patients with scrub typhus, dengue, pancreatitis, and oxygen supplementation had significantly lower mortality. The factors such as advanced age, sepsis, septic shock, liver diseases, and ventilation requirements were observed to be the independent predictors of non-recovery in ARDS patients.

Conclusion

A comparable recovery rate was observed in our population. Advanced age, sepsis, septic shock, liver diseases, and ventilation requirements were the independent predictors of non-recovery.