Outcome prediction for critically ill cirrhotic patients: a comparison of APACHE II and Child-Pugh scoring systems

Evaluation of acute substance abuse patients admitted to the ICU by different scoring system

Drug abuse poisoning is a significant public health problem in many countries all over the world. The recent study aimed to assess the applicability of NEWS II and APACHE II scores as predictors of the ICU admission of acute intoxication by substance abuse. The study enrolled 98 patients admitted to the Alexandria Poison Center of the Main University Hospital (APC-AMUH) with a history of acute intoxication with substance abuse. Collected data included socio-demographic data, circumstances of exposure, and clinical and laboratory data. These data were employed to calculate NEWS II and APACHE II scores. A total of 98 substance abuse patients were admitted. Morphine constituted the highest percentage of substance intoxication (33.7%), followed by methanol (23.5%) and tramadol (17.3%). About one-third of the patients needed the ICU admission (32.7%). The median of NEWS and APACHE II was 7. The mean values of NEWS II and APACHE II in patients who entered the ICU were significantly higher than in patients who did not enter the ICU. The cut-off value of the ROC curve of NEWS II and APACHE II scores for admission to the ICU was 8 for both. These findings suggest that NEWS II and APACHE II scores are good predictors for the evaluation of patients intoxicated by substance abuse who need ICU admission.

Construction and validation of a machine learning-based prediction model for short-term mortality in critically ill patients with liver cirrhosis

OBJECTIVE

Critically ill patients with liver cirrhosis generally have a poor prognosis due to complications such as multiple organ failure. This study aims to develop a machine learning-based prediction model to forecast short-term mortality in critically ill cirrhotic patients in the intensive care unit (ICU), thereby assisting clinical decision-making for intervention and treatment.

METHODS

Machine learning models were developed using clinical data from critically ill cirrhotic patients in the MIMIC database, with multicenter validation performed using data from the eICU database and Qinghai University Affiliated Hospital(QUAH). Various machine learning models, including a Stacking ensemble model, were employed, with the SHAP method used to enhance model interpretability.

RESULTS

The Stacking ensemble model demonstrated superior predictive performance through internal and external validation, with AUC and AP values surpassing those of individual algorithms. The AUC values were 0.845 in the internal validation set, 0.819 in the eICU external validation, and 0.761 in the QUAH validation set. Additionally, the SHAP method highlighted key prognostic variables such as INR, bilirubin, and urine output. The model was ultimately deployed as a web-based calculator for bedside decision-making.

CONCLUSION

The machine learning model effectively predicts short-term mortality risk in critically ill cirrhotic patients in the ICU, showing strong predictive performance and generalizability. The model's robust interpretability and its deployment as a web-based calculator suggest its potential as a valuable tool for assessing the prognosis of cirrhotic patients.

Pulmonary Vascular Permeability and Extravascular Lung Water Index in Patients with Liver Cirrhosis and Septic Shock

Backgrounds and Aims: Patients with cirrhosis are susceptible to sepsis and septic shock. Cirrhotic patients also have increased capillary permeability and are prone to developing volume overload. Patients with septic shock may have an enhanced pulmonary vascular permeability index (PVPI) and extravascular lung water index (EVLWI), both of which are associated with an unfavorable prognosis. It is plausible that pre-existing hyperpermeability may deteriorate when cirrhotic patients develop septic shock. However, it remains unknown whether PVPI and EVLWI can predict the prognosis of cirrhotic patients with septic shock. Pulse Indicator Continuous Cardiac Output (PiCCO) is an established tool to measure PVPI and EVLWI. Therefore, we conducted this retrospective study to investigate the prognostic significance of PVPI and EVLWI in cirrhotic patients with septic shock using PiCCO monitoring. Methods: We included 83 patients with liver cirrhosis and septic shock. EVLW indexed to actual body weight (aEVLWI), EVLW indexed to predicted body weight (pEVLWI), PVPI, disease severity scores, and other biomarkers were analyzed. We collected the PiCCO data on the first 2 days. Results: The overall 28-day mortality was 43.4%. The values of PVPI, aEVLWI, and pEVLWI on day 2 (PVPID2, aEVLWID2, EVLWID2) were significantly higher in non-survivors. The discriminating power of PVPID2 and EVLWID2 to predict 28-day mortality was tested using the area under a ROC curve. The areas under ROC curves (mean ± SEM) were 0.713 ± 0.061 and 0.650 ± 0.063 for PVPID2 and pEVLWID2. In the multivariate analysis, PVPID2, bilirubin, and lactate were independent factors which predicted 28-day mortality. Conclusions: Higher levels of PVPID2 and pEVLWID2 are associated with higher 28-day mortality rates in cirrhotic patients with septic shock. PVPI and pEVLWI may be useful to guide fluid management in this clinical setting.

Assessing the prognosis of cirrhotic patients in the intensive care unit: What we know and what we need to know better

Critically ill cirrhotic patients have high in-hospital mortality and utilize significant health care resources as a consequence of the need for multiorgan support. Despite this fact, their mortality has decreased in recent decades due to improved care of critically ill patients. Acute-on-chronic liver failure (ACLF), sepsis and elevated hepatic scores are associated with increased mortality in this population, especially among those not eligible for liver transplantation. No score is superior to another in the prognostic assessment of these patients, and both liver-specific and intensive care unit-specific scores have satisfactory predictive accuracy. The sequential assessment of the scores, especially the Sequential Organ Failure Assessment (SOFA) and Chronic Liver Failure Consortium (CLIF)-SOFA scores, may be useful as an auxiliary tool in the decision-making process regarding the benefits of maintaining supportive therapies in this population. A CLIF-ACLF > 70 at admission or at day 3 was associated with a poor prognosis, as well as SOFA score > 19 at baseline or increasing SOFA score > 72. Additional studies addressing the prognostic assessment of these patients are necessary.

Clinical Efficacy of Spectral Computed Tomography for Evaluating Liver Function in Patients with Budd-Chiari Syndrome

RATIONALE AND OBJECTIVES

To analyze the clinical relevance of quantitative spectral parameters in evaluating the treatment of patients with Budd-Chiari syndrome (BCS) with different classes of liver function by comparing normalized iodine concentration (NIC) before and after BCS treatment.

MATERIALS AND METHODS

Angiographic data were obtained from 41 patients with confirmed BCS between December 2015 and March 2017. All patients underwent spectral computed tomography (CT) before and after BCS treatment; the average interval between scans was 2-4 months. Iodine concentration and NIC were measured and calculated during the portal venous phase in liver segments I-VIII. Clinical liver function parameters including prothrombin time (PT), albumin (ALB), total bilirubin (TBIL), aspartate aminotransferase, and alanineaminotransferase were recorded. Liver function was classified according to the Child-Pugh grading standard (before treatment). Liver NIC and liver function-related parameters before and after treatment were compared using the paired t-test; Pearson correlation analysiswas performed to analyze the aforementioned parameters among different liver function classes before BCS treatment. p < 0.05 was to be statistically considered significant.

RESULTS

PT and TBIL were negatively correlated with liver NIC (p < 0.05), whereas ALB and liver NIC exhibited a positive correlation (p < 0.05). Comparison of NIC before and after treatment revealed that NIC in liver segments I-VIII was higher after treatment. The p values for segments II-VIII were 0.041, 0.046, 0.041, 0.038, 0.039, 0.042, and 0.040, respectively; the differences were statistically significant (p < 0.05). The increase in NIC in liver segments I-VIII before and after treatment was more significant in patients with class C liver function than in their class B and A counterparts. Comparison of liver function-related parameters revealed that PT was shortened after treatment; ALB levels were increased; and TBIL, alanine aminotransferase, and aspartate aminotransferase levels were decreased.

CONCLUSION

NIC determined through spectral CT was beneficial for evaluating liver function in patients with BCS, and can provide imaging data for reexamination, prognostic evaluation, and follow-up of patients with BCS after treatment. Liver parenchyma NIC values in BCS patients with varying liver function may provide a degree of diagnostic value. Multi-locus and multi-parameter studies of spectral CT can help to further evaluate liver function and assess prognosis in patients with BCS.

A multicenter study on clinical characteristics of Acinetobacter bacteremia in patients with liver cirrhosis

BACKGROUND

Clinical characteristics and risk factors for mortality of Acinetobacter bacteremia in cirrhotic patients have not been investigated.

METHODS

Acinetobacter bacteremia cases from four medical centers were collected from 2009 to 2014, to compare between patients with and without liver cirrhosis. Risk factors for mortality of Acinetobacter bacteremia among cirrhotic patients were identified using multivariate logistic regression.

RESULTS

Among the patients with Acinetobacter bacteremia, 72 had liver cirrhosis and 816 had not. Patients with cirrhosis were younger (57.5 [50-71] vs. 72 [50.25-71], p < 0.001), had more solid tumor (51.4% vs. 31.4%, p = 0.001), lower Acute Physiology and Chronic Health Evaluation II (APACHE II) scores (17 [12-24] vs. 20 [13-28], p = 0.012), less sourced from pneumonia (19.4% vs. 35.8%, p = 0.008), and less caused by Acinetobacterbaumannii (33.3% vs. 50.6%, p = 0.007) than those without. After matching for age, sex, and causative pathogens, the 30-day mortality (34.7% vs. 29.2%, p = 0.592) and APACHE II scores (17 vs. 17, p = 0.769) were not significant. APACHE II score (odds ratio [OR], 1.146; 95% confidence interval [CI], 1.035-1.268; p = 0.009), bacteremia caused by A. baumannii (OR, 20.501; 95% CI, 2.301-182.649; p = 0.007), and solid tumor (OR, 18.073; 95% CI, 1.938-168.504; p = 0.011) were independent risk factors for 30-day mortality of cirrhotic patients with Acinetobacter bacteremia.

CONCLUSION

Even though cirrhotic patients with Acinetobacter bacteremia were younger and had lower APACHE II scores than non-cirrhotic patients, the mortality rates were insignificantly different between the two groups.

Acid-base disorders in liver disease

Alongside the kidneys and lungs, the liver has been recognised as an important regulator of acid-base homeostasis. While respiratory alkalosis is the most common acid-base disorder in chronic liver disease, various complex metabolic acid-base disorders may occur with liver dysfunction. While the standard variables of acid-base equilibrium, such as pH and overall base excess, often fail to unmask the underlying cause of acid-base disorders, the physical-chemical acid-base model provides a more in-depth pathophysiological assessment for clinical judgement of acid-base disorders, in patients with liver diseases. Patients with stable chronic liver disease have several offsetting acidifying and alkalinising metabolic acid-base disorders. Hypoalbuminaemic alkalosis is counteracted by hyperchloraemic and dilutional acidosis, resulting in a normal overall base excess. When patients with liver cirrhosis become critically ill (e.g., because of sepsis or bleeding), this fragile equilibrium often tilts towards metabolic acidosis, which is attributed to lactic acidosis and acidosis due to a rise in unmeasured anions. Interestingly, even though patients with acute liver failure show significantly elevated lactate levels, often, no overt acid-base disorder can be found because of the offsetting hypoalbuminaemic alkalosis. In conclusion, patients with liver diseases may have multiple co-existing metabolic acid-base abnormalities. Thus, knowledge of the pathophysiological and diagnostic concepts of acid-base disturbances in patients with liver disease is critical for therapeutic decision making.

Predicting mortality of patients with cirrhosis admitted to medical intensive care unit: An experience of a single tertiary center

BACKGROUND AND STUDY AIMS

Prognosis for patients with cirrhosis admitted to a medical intensive care unit (MICU) is poor and no previous studies have been published from Qatar or other countries in the region to investigate this issue. The objective of this study was to assess the predictors for in-hospital mortality and admission of cirrhotic patients to MICU in a single tertiary hospital in Qatar.

PATIENTS AND METHODS

All adult cirrhotic MICU patients hospitalized from 2007 through 2012 to Hamad General Hospital-Qatar were included. We compared them to cirrhotic patients admitted to medical wards during same period of time. All data were recorded and analyzed with respect to demographic parameters, clinical features and laboratory as well as radiology characteristics on day one of admission to MICU. Cirrhosis diagnosis was established either with a liver biopsy or the combination of physical, laboratory and radiologic findings. Predictors of mortality were defined by logistic regression analysis.

RESULTS

The cohort comprised 109 cirrhotic MICU patients (86.2% males), and their mean age±SD was 51.6±11.5. MICU-cirrhotic patients had longer hospital stays than medical wards-cirrhotic patients (p=0.01). Admission with severe hepatic encephalopathy, upper gastrointestinal bleeding and SOFA (Sepsis Related Organ Failure Assessment) score were the independent predicting factors for MICU admission. Mortality was higher for the MICU-cirrhotic group than medical wards group (27 (24.8%) deaths vs. 12 (5.3%) deaths, respectively, p=0.001). In multivariate logistic regression analyses, older age>60years (p=0.04), APACH-II score (p=0.001) and MELD score (p=0.02) were independent predicting factors for overall mortality.

CONCLUSION

Severe hepatic encephalopathy, upper gastrointestinal bleeding and SOFA score predict MICU admission of cirrhotic patients. Among MICU cirrhotic patients, older age, APACH-II score and MELD score predict mortality.

Recalibrating the Child-Turcotte-Pugh Score to Improve Prediction of Transplant-Free Survival in Patients with Cirrhosis

BACKGROUND

The Child-Turcotte-Pugh (CTP) score is a widely used and validated predictor of long-term survival in cirrhosis. However, the cutpoints for stratifying laboratory variables in CTP have never been validated.

OBJECTIVE

The objective of this study was to identify evidence-based cutpoints for the CTP laboratory subscores to improve its predictive capacity for transplant-free survival.

DESIGN

Retrospective observational study.

DATA SOURCE

Using a cohort of 30,897 cirrhotic US Veteran patients with at least 5 years of follow-up, we performed Cox proportional hazard survival model iterations varying the upper and lower cutpoints for INR, total bilirubin and albumin CTP subscores. Cutpoints yielding the highest Harrell's C-statistics for concordance with transplant-free survival were incorporated into a modified CTP (mCTP) score. Validation of the mCTP was performed at multiple time frames within the follow-up period of the cohort and within subsets defined by disease etiology.

RESULTS

Modification of CTP cutpoints increased the Harrell's C-statistic for age- and gender-adjusted Cox proportional hazard models from 0.701 ± 0.002 to 0.709 ± 0.002 and the risk ratio per unit change from 1.49 (1.48-1.50) to 1.53 (1.52-1.54). The modified cutpoints showed superiority in predicting 5-year transplant-free survival in various disease etiology subgroups. A mCTP substituting serum creatinine for INR performed superiorly for predicting 5-year transplant-free survival.

CONCLUSION

We propose an evidence-based recalibration of CTP score cutpoints that optimizes this model's capacity to predict transplant-free survival in patients with cirrhosis. The CTP score remains the best predictor of 5-year overall and transplant-free survival in patients with cirrhosis.

Development and Performance of an Algorithm to Estimate the Child-Turcotte-Pugh Score From a National Electronic Healthcare Database

BACKGROUND & METHODS

The Child-Turcotte-Pugh (CTP) score is a widely used and validated predictor of long-term survival in cirrhosis. The CTP score is a composite of 5 subscores, 3 based on objective clinical laboratory values and 2 subjective variables quantifying the severity of ascites and hepatic encephalopathy. To date, no system to quantify CTP score from administrative databases has been validated. The Veterans Outcomes and Costs Associated with Liver Disease study is a multicenter collaborative study to evaluate the outcomes and costs of hepatocellular carcinoma in the U.S. Veterans Health Administration. We developed and validated an algorithm to calculate electronic CTP (eCTP) scores by using data from the Veterans Health Administration Corporate Data Warehouse.

METHODS

Multiple algorithms for determining each CTP subscore from International Classification of Diseases version 9, Common Procedural Terminology, pharmacy, and laboratory data were devised and tested in 2 patient cohorts. For each cohort, 6 site investigators (Boston, Bronx, Brooklyn, Philadelphia, Minneapolis, and West Haven VA Medical Centers) were provided cases from which to determine validity of diagnosis, laboratory data, and clinical assessment of ascites and encephalopathy. The optimal algorithm (designated eCTP) was then applied to 30,840 cirrhotic patients alive in the first quarter of 2008 for whom 5-year overall and transplant-free survival data were available. The ability of the eCTP score and other disease severity scores (Charlson-Deyo index, Veterans Aging Cohort Study index, Model for End-Stage Liver Disease score, and Cirrhosis Comorbidity) to predict survival was then assessed by Cox proportional hazards regression.

RESULTS

Spearman correlations for administrative and investigator validated laboratory data in the HCC and cirrhotic cohorts, respectively, were 0.85 and 0.92 for bilirubin, 0.92 and 0.87 for albumin, and 0.84 and 0.86 for international normalized ratio. In the HCC cohort, the overall eCTP score matched 96% of patients to within 1 point of the chart-validated CTP score (Spearman correlation, 0.81). In the cirrhosis cohort, 98% were matched to within 1 point of their actual CTP score (Spearman, 0.85). When applied to a cohort of 30,840 patients with cirrhosis, each unit change in eCTP was associated with 39% increase in the relative risk of death or transplantation. The Harrell C statistic for the eCTP (0.678) was numerically higher than those for other disease severity indices for predicting 5-year transplant-free survival. Adding other predictive models to the eCTP resulted in minimal differences in its predictive performance.

CONCLUSION

We developed and validated an algorithm to extrapolate an eCTP score from data in a large administrative database with excellent correlation to actual CTP score on chart review. When applied to an administrative database, this algorithm is a highly useful predictor of survival when compared with multiple other published liver disease severity indices.

Allocation of patients with liver cirrhosis and organ failure to intensive care: Systematic review and a proposal for clinical practice

AIM: To propose an allocation system of patients with liver cirrhosis to intensive care unit (ICU), and developed a decision tool for clinical practice.

METHODS: A systematic review of the literature was performed in PubMed, MEDLINE and EMBASE databases. The search includes studies on hospitalized patients with cirrhosis and organ failure, or acute on chronic liver failure and/or intensive care therapy.

RESULTS: The initial search identified 660 potentially relevant articles. Ultimately, five articles were selected; two cohort studies and three reviews were found eligible. The literature on this topic is scarce and no studies specifically address allocation of patients with liver cirrhosis to ICU. Throughout the literature, there is consensus that selection criteria for ICU admission should be developed and validated for this group of patients and multidisciplinary approach is mandatory. Based on current available data we developed an algorithm, to determine if a patient is candidate to intensive care if needed, based on three scoring systems: premorbid Child-Pugh Score, Model of End stage Liver Disease score and the liver specific Sequential Organ Failure Assessment score.

CONCLUSION: There are no established systems for allocation of patients with liver cirrhosis to the ICU and no evidence-based recommendations can be made.

Retrospective evaluation of prognostic score performances in cirrhotic patients admitted to an intermediate care unit

BACKGROUND

The prognosis of cirrhotic patients in the Intensive Care Unit requires the development of predictive tools for mortality. We aimed to evaluate the ability of different prognostic scores to predict hospital mortality in these patients.

METHODS

A single-centre retrospective analysis was conducted of 281 hospital stays of cirrhotic patients at an Intermediate Care Unit between June 2009 and December 2010. The performance of the Simplified Acute Physiology Score (SOFA), the Simplified Acute Physiology Score (SAPS) II or III, Child-Pugh, Model for End-Stage Liver Disease (MELD), MELD-Na and the Chronic Liver Failure-Consortium Acute-on-Chronic Liver Failure score (CLIF-C ACLF) in predicting hospital mortality were compared.

RESULTS

Mean age was 58.2±12.1 years; 77% were male. The main cause of admission was acute gastrointestinal bleeding (47%). The in-hospital mortality rate was 25.3%. Receiver operating characteristic curve analyses demonstrated that SOFA (0.82) MELD-Na (0.82) or MELD (0.81) scores at admission predicted in-hospital mortality better than Child-Pugh (0.76), SAPS II (0.77), SAPS III (0.75) or CLIF-C ACLF (0.75). We then developed the cirrhosis prognostic score (Ci-Pro), which performed better (0.89) than SOFA.

CONCLUSION

SOFA, MELD and especially the Ci-Pro score show the best performance in predicting hospital mortality of cirrhotic patients admitted to an Intermediate Care Unit.

Intensive care unit management of patients with liver failure

Acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) usually mandate management within an intensive care unit (ICU). Even though the conditions bear some similarities, precipitating causes, and systemic complications management practices differ. Although early identification of ALF and ACLF, improvements in ICU management, and the widespread availability of liver transplantation have improved mortality, optimal management practices have not been defined. This article summarizes current ICU management practices and identifies areas of management that require further study.

The Royal Free Hospital score: a calibrated prognostic model for patients with cirrhosis admitted to intensive care unit. Comparison with current models and CLIF-SOFA score

OBJECTIVES

Prognosis for patients with cirrhosis admitted to intensive care unit (ICU) is poor. ICU prognostic models are more accurate than liver-specific models. We identified predictors of mortality, developed a novel prognostic score (Royal Free Hospital (RFH) score), and tested it against established prognostic models and the yet unvalidated Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) model.

METHODS

Predictors of mortality were defined by logistic regression in a cohort of 635 consecutive patients with cirrhosis admitted to ICU (1989-2012). The RFH score was derived using a 75% training and 25% validation set. Predictive accuracy and calibration were evaluated using area under the receiver operating characteristic (AUROC) and goodness-of-fit χ(2) for the RFH score, as well as for SOFA, Model for End-Stage Liver Disease (MELD), Acute Physiology and Chronic Health Evaluation (APACHE II), and Child-Pugh. CLIF-SOFA was applied to a recent subset (2005-2012) of patients.

RESULTS

In-hospital mortality was 52.3%. Mortality improved over time but with a corresponding reduction in acuity of illness on admission. Predictors of mortality in training set, which constituted the RFH score, were the following: bilirubin, international normalized ratio, lactate, alveolar arterial partial pressure oxygen gradient, urea, while variceal bleeding as indication for admission conferred lesser risk. Classification accuracy was 73.4% in training and 76.7% in validation sample and did not change significantly across different eras of admission. The AUROC for the derived model was 0.83 and the goodness-of-fit χ(2) was 3.74 (P=0.88). AUROC for SOFA was 0.81, MELD was 0.79, APACHE II was 0.78, and Child-Pugh was 0.67. In 2005-2012 cohort, AUROC was: SOFA: 0.74, CLIF-SOFA: 0.75, and RFH: 0.78. Goodness-of-fit χ(2) was: SOFA: 6.21 (P=0.63), CLIF-SOFA: 9.18 (P=0.33), and RFH: 2.91 (P=0.94).

CONCLUSIONS

RFH score demonstrated good discriminative ability and calibration. Internal validation supports its generalizability. CLIF-SOFA did not perform better than RFH and the original SOFA. External validation of our model should be undertaken to confirm its clinical utility.

Prognostic scores for cirrhotic patients admitted to an intensive care unit: which consequences for liver transplantation?

Mortality is increased in cirrhotic patients admitted in ICU whatever the admission reason. Prognosis scores assessed in critically ill cirrhotic patients in ICU can be classified in three main categories: liver-specific (CTP and MELD) scores, general (SAPS II and APACHE) scores, and organ failure (OSF and SOFA) scores. The components of the liver-specific scores can be influenced by the acute disease indicating the admission to ICU but those of the non liver-specific scores can be influenced by the underlying liver cirrhosis. Many studies reported that organ failure scores are the best predictors of outcome in cirrhotic patients in ICU. We may wonder if cirrhotic patients with acute organ failures should receive prioritization for organ allocation to save their life or should be denied for a potential futile LT. According to recent studies, the SOFA score is associated with a higher risk of death for patients waiting for LT but could not be associated with a worse outcome after LT. It becomes of paramount importance to correctly identify the cirrhotic patients who will maximally benefit from LT after admission to ICU. The EASL-CLIF Consortium defines the CLIF-SOFA score, redefining the SOFA score with cut-off levels based on mortality prediction. The CLIF-SOFA could represent the ideal score in ICU since it is based on organ failures with cut-off values specifically identified in cirrhotic patients. The validation of the CLIF-SOFA score in critically ill cirrhotic patients admitted to ICU and its usefulness to identify patients who could benefit from LT should be the next steps.

Liver transplantation in the critically ill: a multicenter Canadian retrospective cohort study

Introduction

Critically ill cirrhosis patients awaiting liver transplantation (LT) often receive prioritization for organ allocation. Identification of patients most likely to benefit is essential. The purpose of this study was to examine whether the Sequential Organ Failure Assessment (SOFA) score can predict 90-day mortality in critically ill recipients of LT and whether it can predict receipt of LT among critically ill cirrhosis listed awaiting LT.

Methods

We performed a multicenter retrospective cohort study consisting of two datasets: (a) all critically-ill cirrhosis patients requiring intensive care unit (ICU) admission before LT at five transplant centers in Canada from 2000 through 2009 (one site, 1990 through 2009), and (b) critically ill cirrhosis patients receiving LT from ICU (n = 115) and those listed but not receiving LT before death (n = 106) from two centers where complete data were available.

Results

In the first dataset, 198 critically ill cirrhosis patients receiving LT (mean (SD) age 53 (10) years, 66% male, median (IQR) model for end-stage liver disease (MELD) 34 (26-39)) were included. Mean (SD) SOFA scores at ICU admission, at 48 hours, and at LT were 12.5 (4), 13.0 (5), and 14.0 (4). Survival at 90 days was 84% (n = 166). In multivariable analysis, only older age was independently associated with reduced 90-day survival (odds ratio (OR), 1.07; 95% CI, 1.01 to 1.14; P = 0.013). SOFA score did not predict 90-day mortality at any time. In the second dataset, 47.9% (n = 106) of cirrhosis patients listed for LT died in the ICU waiting for LT. In multivariable analysis, higher SOFA at 48 hours after admission was independently associated with lower probability of receiving LT (OR, 0.89; 95% CI, 0.82 to 0.97; P = 0.006). When including serum lactate and SOFA at 48 hours in the final model, elevated lactate (at 48 hours) was also significantly associated with lower likelihood of receiving LT (0.32; 0.17 to 0.61; P = 0.001).

Conclusions

SOFA appears poor at predicting 90-day survival in critically ill cirrhosis patients after LT, but higher SOFA score and elevated lactate 48 hours after ICU admission are associated with a lower probability receiving LT. Older critically ill cirrhosis patients (older than 60) receiving LT have worse 90-day survival and should be considered for LT with caution.

Review article: towards a considered and ethical approach to organ support in critically-ill patients with cirrhosis

BACKGROUND

Increasing numbers of patients are being admitted to hospital with decompensated chronic liver disease in the UK. A significant proportion will develop complicating extra-hepatic organ dysfunction, but the selection of those who should be admitted to intensive care is complex and challenging. Alcohol-related liver disease also presents complex ethical dilemmas.

AIM

To review recent survival analyses and explore differences in secondary and tertiary care; to highlight strengths and weaknesses of prognostic models, therapeutic advances and shifts in prognostic expectation. We also aim to explore the ethical challenges presented by addiction and self-injury in an area of limited resource.

METHODS

We searched PubMed for articles discussing 'cirrhosis', 'prognosis', 'critical illness', 'organ failure', 'renal failure', 'alcohol', 'ethics' and 'addiction'. We also explored particular ethical dilemmas encountered by the authors and colleagues.

RESULTS

Prognosis has improved in many cirrhotic complications and historically poor outcomes in tertiary care may reflect a more complex patient cohort. Previously 'untreatable' complications are now being managed successfully. Estimates of survival are more accurate after a 48-h period of supportive care. Physicians are not best placed to make judgments with regard to deservingness, moral responsibility, rationing and access to organ support in cases of acute deterioration related to alcoholism, and the case for denying support must be made on purely medical grounds.

CONCLUSIONS

An early, aggressive approach to organ support is justified. Further discussions between hepatologists and critical care physicians are required to determine acceptable burden-to-benefit ratios for prolonged intensive care support in young alcoholic patients.

Perioperative risk factors in patients with liver disease undergoing non-hepatic surgery

The patients with liver disease present for various surgical interventions. Surgery may lead to complications in a significant proportion of these patients. These complications may result in considerable morbidity and mortality. Preoperative assessment can predict survival to some extent in patients with liver disease undergoing surgical procedures. A review of literature suggests nature and the type of surgery in these patients determines the peri-operative morbidity and mortality. Optimization of premorbid factors may help to reduce perioperative mortality and morbidity. The purpose of this review is to discuss the effect of liver disease on perioperative outcome; to understand various risk scoring systems and their prognostic significance; to delineate different preoperative variables implicated in postoperative complications and morbidity; to establish the effect of nature and type of surgery on postoperative outcome in patients with liver disease and to discuss optimal anaesthesia strategy in patients with liver disease.

Acute-on chronic liver failure

Acute-on-chronic liver failure (ACLF) is an increasingly recognised entity encompassing an acute deterioration of liver function in patients with cirrhosis, which is usually associated with a precipitating event and results in the failure of one or more organs and high short term mortality. Prospective data to define this is lacking but there is a large body of circumstantial evidence suggesting that this condition is a distinct clinical entity. From the pathophysiologic perspective, altered host response to injury and infection play important roles in its development. This review focuses upon the current understanding of this syndrome from the clinical, prognostic and pathophysiologic perspectives and indicates potential biomarkers and therapeutic targets for intervention.

Role of predisposition, injury, response and organ failure in the prognosis of patients with acute-on-chronic liver failure: a prospective cohort study

INTRODUCTION

Acute deterioration of cirrhosis is associated with high mortality rates particularly in the patients who develop organ failure (OF), a condition that is referred to as acute-on-chronic liver failure (ACLF), which is currently not completely defined. This study aimed to determine the role of predisposing factors, the nature of the precipitating illness and inflammatory response in the progression to OF according to the PIRO (predisposition, injury, response, organ failure) concept to define the risk of in-hospital mortality.

METHODS

A total of 477 patients admitted with acute deterioration of cirrhosis following a defined precipitant over a 5.5-year period were prospectively studied. Baseline clinical, demographic and biochemical data were recorded for all patients and extended serial data from the group that progressed to OF were analysed to define the role of PIRO in determining in-hospital mortality.

RESULTS

One hundred and fifty-nine (33%) patients developed OF, of whom 93 patients died (58%) compared with 25/318 (8%) deaths in the non-OF group (P < 0.0001). Progression to OF was associated with more severe underlying liver disease and inflammation. In the OF group, previous hospitalisation (P of PIRO); severity of inflammation and lack of its resolution (R of PIRO); and severity of organ failure (O of PIRO) were associated with significantly greater risk of death. In the patients who recovered from OF, mortality at three years was almost universal.

CONCLUSIONS

The results of this prospective study shows that the occurrence of OF alters the natural history of cirrhosis. A classification based on the PIRO concept may allow categorization of patients into distinct pathophysiologic and prognostic groups and allow a multidimensional definition of ACLF.

Predictors of the outcomes of acute-on-chronic hepatitis B liver failure

AIM: To identify the risk factors in predicting the outcome of acute-on-chronic hepatitis B liver failure patients.

METHODS: We retrospectively divided 113 patients with acute-on-chronic liver failure-hepatitis B virus (ACLF-HBV) and without concurrent hepatitis C or D virus infection and hepatocellular carcinoma into two groups according to their outcomes after anti-HBV therapy. Their demographic, clinical, and biochemical data on the day of diagnosis and after the first week of treatment were analyzed using the Mann-Whitney U test, Fisher’s exact test, and a multiple logistic regression analysis.

RESULTS: The study included 113 patients (87 men and 26 women) with a mean age of 49.84 years. Fifty-two patients survived, and 61 patients died. Liver failure (85.2%), sepsis (34.4%), and multiple organ failure (39.3%) were the main causes of death. Multivariate analyses showed that Acute Physiology and Chronic Health Evaluation (APACHE) II scores ≥ 12 [odds ratio (OR) = 7.160, 95% CI: 2.834-18.092, P < 0.001] and positive blood culture (OR = 13.520, 95% CI: 2.740-66.721, P = 0.001) on the day of diagnosis and model for end-stage liver disease (MELD) scores ≥ 28 (OR = 8.182, 95% CI: 1.884-35.527, P = 0.005) after the first week of treatment were independent predictors of mortality.

CONCLUSION: APACHE II scores on the day of diagnosis and MELD scores after the first week of anti-HBV therapy are feasible predictors of outcome in ACLF-HBV patients.

Improvement in the prognosis of cirrhotic patients admitted to an intensive care unit, a retrospective study

OBJECTIVE

To examine how the outcomes of cirrhotic patients admitted to an ICU have changed over time.

METHODS

A retrospective study in a medical ICU during two separate 3-year periods [period 1 (P1): 1995-1998 and period 2 (P2): 2005-2008].

RESULTS

A total of 56 cirrhotic patients were admitted during P1 and 138 during P2, accounting for 2.3 and 4.5% of the total ICU admissions (P<0.01). Patients' characteristics were markedly different between the two periods: previous functional status improved (Knaus scale, A/B/C/D: P1 - 7.1%/53.6%/35.7%/3.6% vs. P2 - 28.2%/47.8%/22.5%/1.5%, P<0.01), the number of comorbidities decreased (Charlson: 1.79±2.22 vs. 1.02±1.40, P=0.02), the severity of cirrhosis increased [Child-Pugh: 8 (7-13) vs. 11 (8-13), P=0.04; Model for End-Stage Liver Disease: 16 (12-28) vs. 22 (15-31), P=0.02], and acute organ dysfunctions increased (Sequential Organ Failure Assessment: 7.3±5.6 vs. 11.3±5.5, P<0.01). The crude in-ICU mortality was similar during the two periods (39.3 vs. 41.3%, P=0.92). However, after adjustment for severity, in-ICU mortality was markedly decreased during P2 (odds ratio: 0.36 [0.15; 0.88], P=0.02).

CONCLUSION

Cirrhotic patients admitted to the ICU have an improved outcome despite increased severity of liver disease. This improvement is associated with a higher selection according to their previous functional status and comorbidities.

Serum lactate level predict mortality in elderly patients with cirrhosis

BACKGROUND

Cirrhotic patients admitted to the intensive care unit (ICU) usually have multi-organ failure. Multiple organ failure entails a very poor outcome in all intensive care patients. Cirrhotic patients show high morbidity and mortality rates compared with other critically ill patients. Severity scores have been developed for cirrhotic patients admitted to ICU. The main aim of this study was to determine whether lactate level gives any predictive value for mortality in cirrhotic elderly patients admitted to the ICU.

METHODS

In all the patients enrolled, a diagnosis of cirrhosis was confirmed either histologically or by resorting to clinical, laboratory, and ultrasonographic findings. During this period, patients with cirrhosis were admitted to the ICU with varying indications. Child-Turcotte-Pugh (CTP), Model for End-stage Liver Disease (MELD), Acute Physiology and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores and lactate were compared between deceased and discharged patients.

RESULTS

A total of 90 consenting patients were enrolled in this study. The mean age of all the patients was 69 ± 5.919. We detected etiological factors for cirrhosis as HBV, HCV, alcohol, and cryptogenic cirrhosis. Hepatorenal syndrome and spontaneous bacterial peritonitis were significantly higher in patients who died than in those who were discharged from the ICU (p values were 0.01 and 0.028, respectively). Lactate level, CTP, APACHE II, MELD and SOFA scores were significantly higher in patients who died than in those who were discharged from the ICU (p values were 0.002,  <  0.001, < 0.001, and < 0.001, respectively).

CONCLUSIONS

Many factors may be useful as a predictor of mortality in ICU in elderly patients with cirrhosis. In terms of prognostic value, the lactate level and APACHE II score are the two best predictive factors in cirrhotic elderly patients admitted to the ICU.

Prevalence and outcome of cirrhosis patients admitted to UK intensive care: a comparison against dialysis-dependent chronic renal failure patients

PURPOSE

Patients with decompensated liver cirrhosis who are admitted to intensive care units (ICU) are perceived, within the UK, as having a particularly poor prognosis.

METHODS

We performed a descriptive analysis of cirrhosis patients admitted to general critical care units 1995-2008 compared to patients admitted with pre-existing chronic renal failure. Data were obtained from the Intensive Care National Audit and Research Centre Case Mix Programme Database incorporating 192 adult critical care units in England, Wales and Northern Ireland.

RESULTS

Cirrhosis accounted for 2.6 % (16,096 patients) of total admissions with mean age 52.5 years and male preponderance (~60 %). Hospital mortality was high (>55 %) although this improved 5 % in recent years, and median length of stay was short (2.5 days). Mortality in cirrhotics with severe sepsis requiring organ support was 65-90 %, compared to 33-39 % in those without. Conversely, patients with chronic renal failure had lower mortality (42 %) despite similar characteristics and higher acute physiology and chronic health evaluation (APACHE) II scores. The APACHE II score under-predicted mortality in cirrhotics.

CONCLUSIONS

Cirrhosis patients exhibit worse outcomes compared to pre-existing renal failure patients, despite similar characteristics. Survival worsens considerably with organ failure, especially with sepsis. They represent a small number of admissions, albeit increasing over recent years, and, in general, have a short ICU stay. Patients with single organ failure have acceptable survival rates and mortality has improved; although we have no data on those refused ICU admission potentially causing survival bias. Given the extremely high mortality in patients with multi-organ failure, support should be limited/withdrawn in such patients.

Clinical profile and predictors of mortality in patients of acute-on-chronic liver failure

BACKGROUND

Acute-on-chronic liver failure (ACLF) is characterised by acute hepatic insult manifesting as jaundice and coagulopathy, complicated within 4 weeks by ascites and/or encephalopathy in patients with previously diagnosed or undiagnosed chronic liver disease. We studied the clinical, biochemical and etiological profiles of ACLF patients investigating variables which could predict mortality.

METHODS

Consecutive ACLF patients were enrolled and given standard intensive care management. They were monitored for predictors of 90-day mortality.

RESULTS

91 patients were included; besides jaundice (median bilirubin 23.1mg/dL) and coagulopathy, acute onset ascites with or without encephalopathy was the presenting symptom in 92%. In all patients a first diagnosis of chronic liver disease was made, mainly due to hepatitis B (37%) or alcohol (34%). Reactivation of chronic hepatitis B and alcoholic hepatitis were the common acute insults. The 90-day mortality was 63%. On multivariate analysis, hepatic encephalopathy, low serum sodium, and high INR were found to be independent baseline predictors of mortality. Amongst all severity scores studied, MELD, SOFA and APACHE-II scores had AUROCs of >0.8 which was significantly higher than that of Child-Turcotte-Pugh.

CONCLUSIONS

ACLF has very high mortality. Hepatic encephalopathy, low serum sodium and high INR predict poor outcome. Mortality can also be predicted by baseline MELD, SOFA or APACHE-II scores.

Intensive care unit admission of decompensated cirrhotic patients: prognostic scoring systems

Cirrhotic patients who need critical care support show high morbidity and mortality rates compared with other critically ill patients. Their prognosis is, in fact, influenced by both the severity of the underlying hepatic disease and the worsening of extrahepatic organ function. Clinicians and investigators have been persistently looking for objective scoring systems capable of providing accurate information on disease severity and short-term prognosis. Risk stratification helps differentiate patients who would not benefit from admission to the intensive care unit (ICU) from those who could achieve better outcomes once aggressively treated. The most common scores, ie, multiple organ dysfunction score, sequential organ failure assessment, and acute physiology and chronic health evaluation, developed in general ICUs to evaluate illness severity, have also been validated to predict the prognosis of cirrhotic patients admitted to the ICU. However, their absolute predictive value has been questioned. A weakness of common prediction models consists in not recognizing the continuum of physiological changes in critically ill decompensated cirrhotic patients. In addition, the predictive power to stratify individual risk is relatively low due to the great variability of liver dysfunction stages, the severity of related manifestations, and the number of nonfunctioning organs on admission. Probability models are not capable of predicting whether a patient will live or die with 100% accuracy, nor can they deny or confirm the indications for mechanical ventilation, vasopressor support or renal replacement therapy, or help to decide when to withhold or withdraw support. Because there are no absolute criteria to predict which cirrhotic decompensated patients will improve with normalization of organ function or deteriorate progressively, a scoring system should be regarded as an adjunct rather than a substitute for clinical judgment in the decision process concerning whether a patient should be admitted to the ICU.

Outcomes of critically ill patients with cirrhosis admitted to intensive care: an important perspective from the non-transplant setting

BACKGROUND

Hospital admissions for cirrhosis have been increasing in the United Kingdom, leading to increased pressure on intensive care (ICU) services. Outcome data for patients admitted to ICU are currently limited to transplant centre reports, with mortality rates exceeding 70%. These tertiary reports could fuel a negative bias when patients with cirrhosis are reviewed for ICU admission in secondary care.

AIMS

To determine whether disease severity and mortality rates in non-transplant general ICU are less severe than those reported by tertiary datasets.

METHODS

A prospective dual-centre non-transplant ICU study. Admissions were screened for cirrhosis and physiological and biochemical data were collected. Disease-specific and critical illness scoring systems were evaluated.

RESULTS

Cirrhosis was present in 137/4198 (3.3%) of ICU admissions. ICU and hospital mortality were 38% and 47%, respectively; median age 50 [43-59] years, 68% men, 72% alcoholic cirrhosis, median Child Pugh Score (CPS) 10 [8-11], Model for End-Stage Liver Disease (MELD) 18 [12-24], Acute Physiology and Chronic Health Evaluation II score (APACHE II) 16 [13-22].

CONCLUSIONS

Mortality rates and disease staging were notably lower than in the published literature, suggesting that patients have a more favourable outlook than previously considered. Transplant centre data should therefore be interpreted with caution when evaluating the merits of intensive care admission for patients in general secondary care ICUs.

Innate immune dysfunction in acute and chronic liver disease

Liver cirrhosis is a common disease causing great public-health concern because of the frequent complications requiring hospital care. Acute liver failure is also prone to several complications but is rare. One of the main complications for both acute and chronic liver diseases is infection, which regularly causes decompensation of cirrhosis, possibly leading to organ failure and death. This review focuses on innate immune function in cirrhosis, acute-on-chronic liver failure and acute liver failure. The known defects of Kupffer cells, neutrophils and monocytes are discussed, together with the pathophysiological importance of gut permeability, portal hypertension and intrinsic cellular defects, and the role of endotoxin, albumin, lipoproteins and toll-like receptors. Based on these different pathomechanisms, the available information on therapeutic strategies is presented. Antibiotic and probiotic treatment, nutritional support, artificial liver support, and experimental strategies such as inhibition of toll-like receptors and use of albumin and colony-stimulating factors are highlighted.

Bacteremia, acute physiology and chronic health evaluation II and modified end stage liver disease are independent predictors of mortality in critically ill nontransplanted patients with acute on chronic liver failure

OBJECTIVES

To determine what physiological and biochemical factors predict development of bacteremia in nontransplanted patients with acute on chronic liver failure and, on diagnosis of bacteremia, what is the natural history of bacteremic patients versus control subjects (acute on chronic liver failure).

INTERVENTIONS

None.

DESIGN

Retrospective analysis of data collected prospectively and entered into a dedicated physiology database.

SETTING

Specialist liver intensive therapy unit.

PATIENTS

Critically ill non-transplanted patients with acute on chronic liver failure admitted between January 2003 and July 2005.

MEASUREMENTS AND MAIN RESULTS

One hundred eighty-four patients were defined with acute on chronic liver failure; 67 (36%) had bacteremia. One hundred seventeen (64%) patients did not (acute on chronic liver failure). Fifty-eight percent of isolates were Gram-negative organisms, 36% were Gram-positives, and 6% fungemia. Median time to first bacteremia was 8 days (range, 3-12 days). On admission (univariate), bacteremic patients had significantly higher Modified End Stage Liver Disease scores (27 vs. 24, p = .037), Acute Physiology and Chronic Health Evaluation II scores (23 vs. 21, p = .049), and greater degrees of encephalopathy (Glasgow Coma Scale score 10 vs. 12, p = .001). During their liver intensive therapy unit course, bacteremic patients had significantly greater requirements for renal replacement therapy (64% vs. 49%, p = .043), mechanical ventilation (88% vs. 68%, p = .002), and a longer median liver intensive therapy unit stay (16 vs. 5 days, p < .001). Survival to hospital discharge was worse in the bacteremic group (25% vs. 56%, p < .001). Multivariate analysis (logistic regression) was performed separately modeling with Acute Physiology and Chronic Health Evaluation II and Modified End Stage Liver Disease. In the first model, Acute Physiology and Chronic Health Evaluation II (odds ratio 1.24) and bacteremia (2.24) were independent predictors of mortality. In the later model, Modified End Stage Liver Disease (odds ratio, 1.06), requirement for renal replacement therapy (3.08), Glasgow Coma Scale (0.72), and bacteremia (2.30) were significant. Both models performed similarly (Modified End Stage Liver Disease area under the receiver operating characteristic curve, 0.864; Acute Physiology and Chronic Health Evaluation II, 0.862).

CONCLUSIONS

In nontransplanted patients with acute on chronic liver failure, bacteremia was associated with increased severity of illness on admission, greater requirements for organ support, and independently adversely impacted on survival. Higher Acute Physiology and Chronic Health Evaluation II and Modified End Stage Liver Disease scores were also independently predictive of mortality.

Prognosis and 1-year mortality of intensive care unit patients with severe hepatic encephalopathy

PURPOSE

Data regarding outcome of patients with chronic liver disease with severe hepatic encephalopathy in intensive care unit are currently scarce.

METHODS

This study is a retrospective observational case series in a medical intensive care unit (ICU) in a university hospital from 1995 to 2005. Patients with hepatic encephalopathy (HE) (admitted with or developing) were identified. Clinical and laboratory parameters were analyzed to determinate predictors of ICU and 1-year mortality.

RESULTS

Seventy-one patients were included (53 male). Median Simplified Acute Physiology Score was 56 with Child-Pugh score 11 +/- 2. Seventy-six percent of patients were admitted with coma (Glasgow Coma Scale, 7.7 +/- 4). Eighty-two percent of patients required intubation, and 28% vasopressors. Thirty-five percent died during ICU stay. At 1 year, mortality was 54%. Univariate analysis identified arterial hypotension, mechanical ventilation, vasopressors at any time, acute renal failure, Simplified Acute Physiology Score, and sepsis associated with ICU mortality. In multivariate analysis, vasopressor use or acute renal failure was the main independent predictor of ICU death and 1-year mortality. Patients free of these risk factors, even requiring intubation, were identified as isolated HE, with lower mortality rates.

CONCLUSION

Predictors of outcome were similar to other groups of patients with liver disease admitted for other reasons. Intensive care unit mortality was lower than reported for other groups of patients with similar illness. Patients with severe HE admitted to ICU with no organ dysfunction other than mechanical ventilation had a better outcome and may require ICU admission.

Models for prediction of mortality from cirrhosis with special reference to artificial neural network: a critical review

Prediction of mortality of patients with cirrhosis of liver, a common and potentially fatal disease, is important for timely listing of patients for liver transplantation. The Child-Pugh scoring system has been widely used for predicting the outcome of liver cirrhosis. The Model for End-Stage Liver Disease (MELD) score has recently become popular for prediction of short-term mortality for organ allocation. A few studies that evaluated artificial neural network (ANN)-based model for prediction of outcome of cirrhosis of liver in terms of mortality have consistently shown it to be superior to Child-Pugh scoring and logistic regression-based models; it is worth noting that MELD score is also derived using the logistic regression model. Due to the inherent ability of neural network-based systems in identifying complex nonlinear interactions, ANN-based models are expected to perform better than most linear models, such as regression-based models. More studies are needed on ANN-based models for prediction of mortality of patients with cirrhosis of liver and its value in prioritization of organ allocation for treatment of patients with cirrhosis of liver.

Acid-base disturbances in critically ill patients with cirrhosis

BACKGROUND/AIMS

The equilibrium of offsetting metabolic acid-base disorders in stable cirrhosis might be lost during episodes of hepatic decompensation, haemorrhage or sepsis. The purpose of this study was to determine whether the acid-base state is destabilized in critically ill patients with cirrhosis and whether this is associated with mortality.

PATIENTS AND METHOD

One-hundred and eighty-one consecutive patients with cirrhosis were investigated in a prospective observational cohort study on admission to a medical intensive care unit (ICU) of a university hospital. Arterial acid-base state was assessed according to the Gilfix methodology. Clinical data, ICU mortality and hospital mortality were recorded.

MAIN RESULTS

Patients had net metabolic acidosis owing to unmeasured anions and owing to hyperchloraemic, dilutional and lactic acidosis. Lactic acidosis, acidemia and acute renal failure on ICU admission were associated with increased mortality. Lactate and pH discriminated survivors from non-survivors. The presence of lactic acidosis could not always be recognized by customary acid-base parameters.

CONCLUSION

The stable equilibrium of acid-base disorders is lost when patients with cirrhosis become critically ill. Lactic acidosis and acidaemia are associated with increased ICU mortality caused by severe underlying organ dysfunction.

Evaluation of the performance of a modified Acute Physiology and Chronic Health Evaluation (APACHE II) scoring system for critically ill patients in emergency departments in Hong Kong

INTRODUCTION

Numerous prognostic predictive models have been developed for critically ill patients, many of which are primarily designed for use in intensive care units. The objective of this study was to evaluate the accuracy of a modified Acute Physiology and Chronic Health Evaluation (APACHE II) scoring system in predicting the mortality for critically ill patients managed in emergency department (ED) resuscitation rooms in Hong Kong.

METHOD

A multi-centre, prospective study was conducted for patients managed in the resuscitation rooms of the EDs of four major hospitals, including one university teaching hospital. The primary outcome measure was 14 day all-cause mortality and the secondary outcome measure was the length of stay in hospital.

RESULTS

Of 867 patients recruited between 4 and 30 April 2004, 106 (12.2%) patients died. The modified APACHE II score was found to be significantly higher in non-survivors compared to survivors (mean+/-S.D.: 21.2+/-7.7 versus 14.4+/-7.1, p<0.001). The area under the curve for modified APACHE II in predicting mortality was 0.743 (95% CI, 0.696-0.790).

CONCLUSION

The modified APACHE II score is only a moderate predictor of mortality for critically ill patients managed in the resuscitation rooms of EDs in Hong Kong. A more ED specific scoring method is required.

Review article: scoring systems for assessing prognosis in critically ill adult cirrhotics

BACKGROUND

Cirrhotic patients admitted to intensive care units (ICU) still have poor outcomes. Some current ICU prognostic models [Acute Physiology and Chronic Health Evaluation (APACHE), Organ System Failure (OSF) and Sequential Organ Failure Assessment (SOFA)] were used to stratify cirrhotics into risk categories, but few cirrhotics were included in the original model development. Liver-specific scores [Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD)] could be useful in this setting.

AIM

To evaluate whether ICU prognostic models perform better compared with liver-disease specific ones in cirrhotics admitted to ICU.

METHODS

We performed a structured literature review identifying clinical studies focusing on prognosis and risk factors for mortality in adult cirrhotics admitted to ICU.

RESULTS

We found 21 studies (five solely dealing with gastrointestinal bleeding) published during the last 20 years (54-420 patients in each). APACHE II and III, SOFA and OSF had better discrimination for correctly predicting death compared with the CTP score. The MELD score was evaluated only in one study and had good predictive accuracy [receiver operator characteristic (ROC) curve: 0.81). Organ dysfunction models (OSF, SOFA) were superior compared with APACHE II and III (ROC curve: range 0.83-0.94 vs. 0.66-0.88 respectively). Cardiovascular, liver and renal system dysfunction were more frequently independently associated with mortality.

CONCLUSIONS

General-ICU models had better performance in cirrhotic populations compared with CTP score; OSF and SOFA had the best predictive ability. Further prospective and validation studies are needed.

Risk factors, sequential organ failure assessment and model for end-stage liver disease scores for predicting short term mortality in cirrhotic patients admitted to intensive care unit

BACKGROUND

Prognostic scores in an intensive care unit (ICU) evaluate outcomes, but derive from cohorts containing few cirrhotic patients.

AIMS

To evaluate 6-week mortality in cirrhotic patients admitted to an ICU, and to compare general and liver-specific prognostic scores.

METHODS

A total of 312 consecutive cirrhotic patients (65% alcoholic; mean age 49.6 years). Multivariable logistic regression to evaluate admission factors associated with survival. Child-Pugh, Model for End-stage Liver Disease (MELD), Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores were compared by receiver operating characteristic curves.

RESULTS

Major indication for admission was respiratory failure (35.6%). Median (range) Child-Pugh, APACHE II, MELD and SOFA scores were 11 (5-15), 18 (0-44), 24 (6-40) and 11 (0-21), respectively; 65% (n = 203) died. Survival improved over time (P = 0.005). Multivariate model factors: more organs failing (FOS) (<3 = 49.5%, > or =3 = 90%), higher FiO(2), lactate, urea and bilirubin; resulting in good discrimination [area under receiver operating characteristic curve (AUC) = 0.83], similar to SOFA and MELD (AUC = 0.83 and 0.81, respectively) and superior to APACHE II and Child-Pugh (AUC = 0.78 and 0.72, respectively).

CONCLUSIONS

Cirrhotics admitted to ICU with > or =3 failing organ systems have 90% mortality. The Royal Free model discriminated well and contained key variables of organ function. SOFA and MELD were better predictors than APACHE II or Child-Pugh scores.

Extracorporal liver support with molecular adsorbents recirculating system in patients with hepatitis B-associated fulminant hepatic failure

Hepatitis B virus (HBV) infection is the most prevalent cause of fulminant hepatic failure (FHF) in the Far East. HBV-associated FHF is characterised by rapidly progressive end organ dysfunction/failure and a very poor prognosis. To investigate how molecular adsorbent recirculating system (MARS) treatment impacts multiple organ system function in HBV-associated FHF. Ten consecutive patients were treated with MARS in a period of 12 months. Clinical, biochemical and haemodynamic parameters were assessed before and after MARS. Various disease severity scoring systems including model for end-stage liver disease, APACHE II, APACHE III, sequential organ failure assessment and organ system failure scores were also assessed. There were significant improvements in hepatic encephalopathy grading (p < 0.001), mean arterial pressure (p < 0.001), plasma renin activity (p = 0.027), bilirubin (p < 0.001), ammonia (p = 0.001) and creatinine levels (p < 0.001). There were also significant improvements in all the scoring systems evaluated. Meanwhile, platelet count was significantly decreased (p < 0.001). One patient was successfully bridged to liver transplantation. Three patients were alive at 3 months of follow-up. MARS can improve multiple organ functions in HBV-associated FHF. On the basis of these findings, randomised controlled studies are indicated and justified.

Bench-to-bedside review: outcome predictions for critically ill patients in the emergency department

The escalating number of emergency department (ED) visits, length of stay, and hospital overcrowding have been associated with an increasing number of critically ill patients cared for in the ED. Existing physiologic scoring systems have traditionally been used for outcome prediction, clinical research, quality of care analysis, and benchmarking in the intensive care unit (ICU) environment. However, there is limited experience with scoring systems in the ED, while early and aggressive intervention in critically ill patients in the ED is becoming increasingly important. Development and implementation of physiologic scoring systems specific to this setting is potentially useful in the early recognition and prognostication of illness severity. A few existing ICU physiologic scoring systems have been applied in the ED, with some success. Other ED specific scoring systems have been developed for various applications: recognition of patients at risk for infection; prediction of mortality after critical care transport; prediction of in-hospital mortality after admission; assessment of prehospital therapeutic efficacy; screening for severe acute respiratory syndrome; and prediction of pediatric hospital admission. Further efforts at developing unique physiologic assessment methodologies for use in the ED will improve quality of patient care, aid in resource allocation, improve prognostic accuracy, and objectively measure the impact of early intervention in the ED.