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Goble SR, Ismail AS, Debes JD, Leventhal TM. Critical care outcomes in decompensated cirrhosis: a United States national inpatient sample cross-sectional study. Crit Care 2024; 28:150. [PMID: 38715040 PMCID: PMC11077702 DOI: 10.1186/s13054-024-04938-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 04/30/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Prior assessments of critical care outcomes in patients with cirrhosis have shown conflicting results. We aimed to provide nationwide generalizable results of critical care outcomes in patients with decompensated cirrhosis. METHODS This is a retrospective study using the National Inpatient Sample from 2016 to 2019. Adults with cirrhosis who required respiratory intubation, central venous catheter placement or both (n = 12,945) with principal diagnoses including: esophageal variceal hemorrhage (EVH, 24%), hepatic encephalopathy (58%), hepatorenal syndrome (HRS, 14%) or spontaneous bacterial peritonitis (4%) were included. A comparison cohort of patients without cirrhosis requiring intubation or central line placement for any principal diagnosis was included. RESULTS Those with cirrhosis were younger (mean 58 vs. 63 years, p < 0.001) and more likely to be male (62% vs. 54%, p < 0.001). In-hospital mortality was higher in the cirrhosis cohort (33.1% vs. 26.6%, p < 0.001) and ranged from 26.7% in EVH to 50.6% HRS. Mortality when renal replacement therapy was utilized (n = 1580, 12.2%) was 46.5% in the cirrhosis cohort, compared to 32.3% in other hospitalizations (p < 0.001), and was lowest in EVH (25.7%) and highest in HRS (51.5%). Mortality when cardiopulmonary resuscitation was used was increased in the cirrhosis cohort (88.0% vs. 72.1%, p < 0.001) and highest in HRS (95.7%). CONCLUSIONS One-third of patients with cirrhosis requiring critical care did not survive to discharge in this U.S. nationwide assessment. While outcomes were worse than in patients without cirrhosis, the results do suggest better outcomes compared to previous studies.
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Affiliation(s)
- Spencer R Goble
- Department of Medicine, Hennepin Healthcare, 730 South 8th Street, Minneapolis, MN, 55415, USA.
| | - Abdellatif S Ismail
- Department of Internal Medicine, University of Maryland Medical Center Midtown Campus, 827 Linden Ave, Baltimore, MD, 21201, USA
| | - Jose D Debes
- Department of Medicine, University of Minnesota, Mayo Memorial Building, MMC 250, 420 Delaware Street S.E., Minneapolis, MN, 55455, USA
| | - Thomas M Leventhal
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, MMC 36, 420 Delaware Street S.E., Minneapolis, MN, 55455, USA
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Shimoda-Sakano TM, Paiva EF, Schvartsman C, Reis AG. Factors associated with survival and neurologic outcome after in-hospital cardiac arrest in children: A cohort study. Resusc Plus 2023; 13:100354. [PMID: 36686327 PMCID: PMC9852640 DOI: 10.1016/j.resplu.2022.100354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/26/2022] [Accepted: 12/28/2022] [Indexed: 01/13/2023] Open
Abstract
Aim In-hospital paediatric cardiopulmonary resuscitation (CPR) survival has been improving in high-income countries. This study aimed to analyse factors associated with survival and neurological outcome after paediatric CPR in a middle-income country. Methods This observational study of in-hospital cardiac arrest using Utstein-style registry included patients <18 years old submitted to CPR between 2015 and 2020, at a high-complexity hospital. Outcomes were survival and neurological status assessed using Paediatric Cerebral Performance Categories score at prearrest, discharge, and after 180 days. Results Of 323 patients who underwent CPR, 108 (33.4%) survived to discharge and 93 (28.8%) after 180 days. In multivariable analysis, lower survival at discharge was associated with liver disease (OR 0.060, CI 0.007-0.510, p = 0.010); vasoactive drug infusion before cardiac arrest (OR 0.145, CI 0.065-0.325, p < 0.001); shock as the immediate cause (OR 0.183, CI 0.069-0.486, p = 0.001); resuscitation > 30 min (OR 0.070, CI 0.014-0.344, p = 0.001); and bicarbonate administration during CPR (OR 0.318, CI 0.130-0.780, p = 0.01). The same factors remained associated with lower survival after 180 days. Neurological outcome was analysed in the 93 survivors after 180 days following CPR. Prearrest neurological dysfunction was observed in 31.4%, and neurological prognosis was favourable in 79.7% at discharge and similar after 180 days. Conclusion In-hospital paediatric cardiac arrest patients with complex chronic conditions had lower survival associated with liver disease, shock as cause of cardiac arrest, vasoactive drug infusion before cardiac arrest, bicarbonate administration during CPR, and prolonged resuscitation. Most survivors had favourable neurological outcome.
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Affiliation(s)
- Tania M. Shimoda-Sakano
- University of Sao Paulo Children Institute, São Paulo, SP, Brazil
- Corresponding author at: R. Santa Justina, 215 ap 62, CEP 04545-041 São Paulo, Brazil.
| | | | | | - Amelia G. Reis
- University of Sao Paulo Children Institute, São Paulo, SP, Brazil
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Orman ES, Yousef A, Xu C, Shamseddeen H, Johnson AW, Nephew L, Ghabril M, Desai AP, Patidar KR, Chalasani N. Palliative Care, Patient-Reported Measures, and Outcomes in Hospitalized Patients With Cirrhosis. J Pain Symptom Manage 2022; 63:953-961. [PMID: 35202730 PMCID: PMC9124687 DOI: 10.1016/j.jpainsymman.2022.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/08/2022] [Accepted: 02/15/2022] [Indexed: 11/18/2022]
Abstract
CONTEXT Studies of palliative care (PC) in hospitalized patients with cirrhosis have been retrospective, with limited evaluation of patient-reported measures and outcomes. OBJECTIVES To examine the relationship between PC, patient-reported measures (quality of life and functional status), and outcomes. METHODS We performed a prospective cohort study of patients with cirrhosis hospitalized from 2014 to 2019. We recorded PC consultation details, quality of life (chronic liver disease questionnaire), and functional status (functional status questionnaire). Patients were followed for 90 days to assess readmissions, costs, and mortality. RESULTS Seventy-four of 679 patients saw PC, often later in the hospitalization (median hospital day 8; IQR 4-16). Those who saw PC had greater Charlson comorbidity index (mean 6.8 vs. 5.9), MELD (mean 25 vs. 20), and prior 30-day admission (47% vs. 35%). Compared to those who did not see PC, PC patients had greater impairments in intermediate activities of daily living (83% vs. 72%), social activity (72% vs. 59%), quality of interactions (49% vs. 36%), abdominal symptoms (mean score 3.1 vs. 3.6), activity (mean 3.3 vs. 3.6), and overall quality of life (mean 3.6 vs. 3.8). PC was associated with fewer transfusions and upper endoscopies and with greater completion of advanced directives. After multivariable adjustment, PC was not associated with intensive care, 30-day readmissions, 90-day costs, or mortality. CONCLUSION PC occurs infrequently and late in those with more severe liver disease and functional impairment. PC may be associated with reduction in utilization and greater completion of advanced directives. Randomized trials are needed to evaluate PC for this population.
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Affiliation(s)
- Eric S Orman
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA.
| | - Andrew Yousef
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Chenjia Xu
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Hani Shamseddeen
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Amy W Johnson
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Archita P Desai
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Kavish R Patidar
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
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Kabaria S, Gupta K, Bhurwal A, Patel AV, Rustgi VK. Predictors of do-not-resuscitate order utilization in decompensated cirrhosis hospitalized patients: A nationwide inpatient cohort study. Ann Hepatol 2021; 22:100284. [PMID: 33160032 DOI: 10.1016/j.aohep.2020.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Decompensated cirrhosis carries high inpatient morbidity and mortality. Consequently, advance care planning is an integral aspect of medical care in this patient population. Our study aims to identify do-not-resuscitate (DNR) order utilization and demographic disparities in decompensated cirrhosis patients. PATIENTS OR MATERIALS AND METHODS Nationwide Inpatient Sample was used to extract the cohort of patients from January 1st, 2016 to December 31st, 2017, based on the most comprehensive and recent data. The first cohort included hospitalized patients with decompensated cirrhosis. The second cohort included patients with decompensated cirrhosis with at least one contraindication for liver transplantation. RESULTS A cohort of 585,859 decompensated cirrhosis patients was utilized. DNR orders were present in 14.2% of hospitalized patients. DNR utilization rate among patients with relative contraindication for liver transplantation was 15.0%. After adjusting for co-morbid conditions, disease severity, and inpatient mortality, African-American and Hispanic patient populations had significantly lower DNR utilization rates. There were regional, and hospital-level differences noted. Moreover, advanced age, advanced stage of decompensated cirrhosis, inpatient mortality, and relative contraindications for liver transplantation (metastatic neoplasms, dementia, alcohol misuse, severe cardiopulmonary disease, medical non-adherence) were independently associated with increased DNR utilization rates. CONCLUSIONS The rate of DNR utilization in patients with relative contraindications for liver transplantation was similar to patients without any relative contraindications. Moreover, there were significant demographic and hospital-level predictors of DNR utilization. This information can guide resource allocation in educating patients and their families regarding prognosis and outcome expectations.
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Affiliation(s)
- Savan Kabaria
- Internal Medicine, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, 08901, United States.
| | - Kapil Gupta
- Division of Gastroenterology and Hepatology, Robert Wood Johnson School of Medicine, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, 08901, United States
| | - Abhishek Bhurwal
- Division of Gastroenterology and Hepatology, Robert Wood Johnson School of Medicine, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, 08901, United States
| | - Anish V Patel
- Division of Gastroenterology and Hepatology, Robert Wood Johnson School of Medicine, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, 08901, United States
| | - Vinod K Rustgi
- Division of Gastroenterology and Hepatology, Robert Wood Johnson School of Medicine, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, 08901, United States
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