Early mechanical ventilation for grade IV hepatic encephalopathy is associated with increased mortality among patients with cirrhosis: an exploratory study

Abstract

Background: Unresponsive patients with toxic-metabolic encephalopathies often undergo endotracheal intubation for the primary purpose of preventing aspiration events. However, among patients with pre-existing systemic comorbidities, mechanical ventilation itself may be associated with numerous risks such as hypotension, aspiration, delirium, and infection. Our primary aim was to determine whether early mechanical ventilation for airway protection was associated with increased mortality in patients with cirrhosis and grade IV hepatic encephalopathy. Methods: The National Inpatient Sample was queried for hospital stays due to grade IV hepatic encephalopathy among patients with cirrhosis between 2016 and 2019. After applying our exclusion criteria, including cardiopulmonary failure, data from 1,975 inpatient stays were analyzed. Patients who received mechanical ventilation within 2 days of admission were compared to those who did not. Univariable and multivariable logistic regression analyses were performed to identify clinical factors associated with in-hospital mortality. Results: Of 162 patients who received endotracheal intubation during the first 2 hospital days, 64 (40%) died during their hospitalization, in comparison to 336 (19%) of 1,813 patients in the comparator group. In multivariable logistic regression analysis, mechanical ventilation was the strongest predictor of in-hospital mortality in our primary analysis (adjusted odds ratio, 3.00; 95% confidence interval, 2.14-4.20; P<0.001) and in all sensitivity analyses. Conclusions: Mechanical ventilation for the sole purpose of airway protection among patients with cirrhosis and grade IV hepatic encephalopathy may be associated with increased in-hospital mortality. Future studies are necessary to confirm and further characterize our findings.

Development and validation of a nomogram for predicting in-hospital mortality of intensive care unit patients with liver cirrhosis

“…The need for airway protection due to hepatic coma and respiratory failure resulting from lung infection, pleural effusion, hepatopulmonary syndrome, etc. , are the main reasons why liver cirrhosis patients are admitted to the ICU for respiratory support[ 36 , 37 ]. Mechanical ventilation has been demonstrated to be associated with poorer prognosis in several studies[ 38 , 39 ].…”

Using machine learning methods to predict 28-day mortality in patients with hepatic encephalopathy

“…And researchers also found that the use of mechanical ventilation was a significant risk factor for mortality [ 37 ]. The study by Saffo S et al has demonstrated that mechanical ventilation was the strongest predictor of in-hospital mortality in their primary analysis (OR, 3.00; 95% CI, 2.14–4.20; P < 0.001) and in all sensitivity analyses [ 38 ]. Studies by Benhaddouch Z et al came to similar conclusion [ 8 ].…”

Review article: Evaluation and care of the critically ill patient with cirrhosis

“…Thus, the potential benefit of early endotracheal intubation in those with grade IV hepatic encephalopathy is uncertain, although the high mortality risk may be a function of the severity of liver disease and not necessarily that of the grade of HE. 55 Lung-protective techniques can be used in critically ill patients with cirrhosis, especially in the setting of ARDS. In patients without ARDS, low tidal volume ventilation at 6 mL/kg predicted body weight (PBW) versus 10 mL/kg PBW showed no difference in outcomes, provided that the plateau pressure was maintained below 25 cm H 2 O.…”

“…Intubation within the first two hospital days was linked to a 40% mortality rate, compared to 19% in non‐ventilated patients. Thus, the potential benefit of early endotracheal intubation in those with grade IV hepatic encephalopathy is uncertain, although the high mortality risk may be a function of the severity of liver disease and not necessarily that of the grade of HE 55 …”