Effect of liver cirrhosis on long-term outcomes after acute respiratory failure: A population-based study

Rate of Successful Extubation in Mechanically Ventilated Patients with Cirrhosis and Hepatic Coma

BACKGROUND

The prognosis of critically ill patients with cirrhosis who require mechanical ventilation is guarded. Data are lacking for the optimal therapeutic approach to hepatic encephalopathy (HE) in the ventilated patient.

METHODS

Retrospective cohort analysis of 314 encounters (298 patients) with cirrhosis who underwent mechanical ventilation in a medical ICU and were ordered at least 1 dose of lactulose. Hazard of extubation alive was determined using a competing risk model. Primary exposures were HE therapy (lactulose and rifaximin) which were adjusted for the indication for ventilation (HE, procedures, respiratory failure), age, MELD-Na, and compensation status.

RESULTS

Indications for ventilation were 22.3% for grade 4 HE, 29.9% for procedures, and 47.8% for respiratory or cardiovascular failure. Median length of intubation was 2.63 days; death rate on ventilator was 31.2%. Relative to intubation for procedure, hazard of extubation for intubation for HE was 0.34 (95% confidence interval (CI): 0.22-0.52) and 0.33 (CI: 0.23-0.47) for respiratory failure. Hazard of extubation for rifaximin administration within 24-h after intubation was significant at 1.74 (1.21-2.50). Lactulose dosing was not significant for hazard of extubation.

DISCUSSION

Mortality is high for all patients with cirrhosis requiring mechanical ventilation, including those intubated for grade 4 HE. Efforts to optimize the odds of successful extubation are urgently needed. Our findings suggest improved incidence of extubation associated with rifaximin administration in the first 24-h after intubation. Prospective, multi-center data to confirm these findings in this vulnerable population are warranted.

Cirrhotic Patients on Mechanical Ventilation Have a Low Rate of Successful Extubation and Survival

BACKGROUND AND AIMS

We hypothesized that mechanically ventilated cirrhotic patients not only have poor outcomes, but also that certain clinical variables are likely to be associated with mortality. We aimed to describe the predictors of mortality in these patients.

METHODS

This observational study examined 113 mechanically ventilated cirrhotic patients cared for at our institution between July 1, 2014, and February 28, 2018. We performed bivariate and multivariate analyses to identify risk factors for mortality on mechanical ventilation and created an equation to calculate probability of mortality based on these variables.

RESULTS

Seventy percent of patients had a history of a decompensating event. Altered mental status was the most frequently encountered indication for intubation (46%). 53% patients died on mechanical ventilation. After controlling for variables associated with increased mortality, multivariate analysis revealed that vasopressor use was the strongest predictor of mortality on mechanical ventilation (OR = 9.3) followed by sepsis (OR = 4.1). A formula with an area under the curve of 0.85 was obtained in order to predict the probability of mortality for cirrhotic patients on mechanical ventilation (available at https://medweb.musc.edu/mvcp/ ). This model (AUC = 0.85) outperformed the CLIF-SOFA score (AUC = 0.68) in predicting mortality in this cohort.

CONCLUSION

Cirrhotic patients requiring mechanical ventilation have an extremely poor prognosis, and in patients requiring vasopressors, having a history of decompensation, sepsis or low albumin, mortality is higher. Our data points to the clinical variables should be considered in the medical management of these patients and provide physicians with a formula to predict the probability of mortality.

Hepatic manifestations and impact of COVID-19 on the cirrhotic patient

El coronavirus SARS-CoV-2, un nuevo coronavirus, es responsable de la enfermedad infecciosa por coronavirus 19 (COVID-19). A nivel global, esta pandemia va en crecimiento y pudiera afectar al 50-60% de la población mundial en los siguientes meses. Si bien es una enfermedad cuya manifestación más severa es la neumonía atípica y sepsis, recientemente se ha descrito que el tracto digestivo y en particular el hígado, pueden verse afectados por el SARS-CoV-2. Así pues, el objetivo del presente trabajo es revisar la literatura disponible al respecto y emitir algunas recomendaciones del papel que el COVID-19 ejerce sobre el hígado en la salud y la enfermedad. La incidencia de lesión hepática asociada específicamente a COVID-19 varía de 14.8-53%. La mayoría de las series de casos han reportado alteración en ALT y AST, elevación de bilirrubinas totales y albúmina sérica baja. La afectación hepática se ha asociado a casos más graves de COVID-19. Por otra parte, se reconoce que la cirrosis hepática es un estado de disfunción inmune que comprende inmunodeficiencia e inflamación sistémica, lo cual hace razonable que estos pacientes sean más susceptibles a la infección por SARS-CoV-2. Las recomendaciones para estos pacientes, además de las medidas generales para la población (aislamiento social, lavado de manos) incluyen el apoyo social, médico y psicológico durante el período de estancia en el domicilio para evitar transgresiones a la terapia. Es recomendable orientar a los pacientes a mantenerse informados de los cambios en recomendaciones y políticas sociales.

Prognostic value of international normalized ratio to albumin ratio among critically ill patients with cirrhosis

BACKGROUND AND AIM

Critically ill patients with cirrhosis are at an increased risk of mortality. Our study aimed to externally validate the ability of the prothrombin time-international normalized ratio to albumin ratio (PTAR), an objective and simple scoring system, to predict 90-day mortality in critically ill patients with cirrhosis.

PATIENTS AND METHODS

A total of 865 patients were entered into the study, and all the participants were followed up for at least 90 days. Clinical parameters on the first day of intensive care unit admission were included to compare survivors with nonsurvivors.

RESULTS

After multivariable adjustment, the association between the risk of 90-day mortality and PTAR remained statistically significant with a hazard ratio of 2.71 (95% confidence interval: 1.99-3.68). The PTAR score showed good discrimination ability for predicting 90-day mortality with an area under receiver operating characteristic curve of 0.72 (95% confidence interval: 0.68-0.75). To improve its feasibility, we regrouped the PTAR scores into three levels of risk (low risk: <0.55, intermediate risk: 0.55-1.00, and high risk: ≥1.00); the 90-day mortality rates were 20.1% (74/368), 41.7% (168/403), and 73.4% (69/94), respectively.

CONCLUSION

The PTAR score system is a convenient and practical tool for predicting the prognosis of critically ill patients with cirrhosis.

Prognosis of patients with acute respiratory failure and prolonged intensive care unit stay

Background

Reasons for the prolonged critical care support include uncertainty of outcome, the complex dynamic created between physicians with care team members and the patient's family over a general unwillingness to surrender to unfavorable outcomes. The purpose of this study was to investigate outcomes and identify risk factors of patients with acute respiratory failure (ARF) who required a prolonged intensive care unit (ICU) stay (≥21 days). It may provide reference to screen patients who are suitable for hospice care.

Methods

The medical records of all ARF patients with a prolonged ICU stay were retrospectively reviewed. The primary outcome was in-hospital mortality.

Results

We identified 1,189 patients. Sepsis (n=896, 75.4%) was the most common cause of prolonged ICU stays, following by renal failure (n=232, 19.5%), and unstable hemodynamic status vasopressors or arrhythmia (n=208, 17.5%). Using multivariable logistic regression, we identified eight risk factors of death: age >75 years, ICU stay for more than 28 days, APACHE II score ≥25, unstable hemodynamic status, renal failure, hepatic failure, massive gastrointestinal tract bleeding, and using a fraction of inspired oxygen (FiO₂) ≥40%. The overall in-hospital mortality rate was 53.6% (n=637), and it up to 75.3% (216/287) for patients with at least three risk factors.

Conclusions

The outcome of patients with ARF who required prolonged ICU stay was poor. They had a high risk of in-hospital mortality. Palliative care should be considered as a reasonable option for the patients at high risk of death.

Prognostic factors and outcomes of unplanned extubation

This study investigated the prognostic factors and outcomes of unplanned extubation (UE) in patients in a medical center’s 6 intensive care units (ICUs) and calculated their mortality risk. We retrospectively reviewed the medical records of all adult patients in Chi Mei Medical Center who underwent UE between 2009 and 2015. During the study period, there were 305 episodes of UE in 295 ICU patients (men: 199 [67.5%]; mean age: 65.7 years; age range: 18–94 years). The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 16.4, mean therapeutic intervention scoring system (TISS) score was 26.5, and mean Glasgow coma scale score was 10.4. One hundred thirty-six patients (46.1%) were re-intubated within 48 h. Forty-five died (mortality rate: 15.3%). Multivariate analyses showed 5 risk factors—respiratory rate, APACHE II score, uremia, liver cirrhosis, and weaning status—were independently associated with mortality. In conclusion, five risk factors including a high respiratory rate before UE, high APACHE II score, uremia, liver cirrhosis, and not in the process of being weaned—were associated with high mortality in patients who underwent UE.