Intensive care unit admissions with cirrhosis: Risk-stratifying patient groups and predicting individual survival

Abstract

Prognosis for acutely ill patients with cirrhosis is in-hepatic portosystemic shunting 3-7 and other operative fluenced by the severity of hepatic abnormalities and by procedures. [8][9][10][11] These systems have also been useful for dysfunction of other organ systems. The purpose of this risk-stratifying groups of patients with cirrhosis, [12][13][14][15] in study was to examine the usefulness of the Acute Physi-evaluating therapy for complications of cirrhosis, [16][17][18] ology, Age, and Chronic Health Evaluation (APACHE III) and in assessing the efficacy of procedures such as prognostic system for risk-stratifying groups of inten-sclerotherapy. [19][20][21] Although useful for clinical trials, sive care unit (ICU) patients with cirrhosis and in pre-the Child-Pugh classification has limited predictive acdicting individual survival. We used data for 17,440 ICU curacy for individuals because of overlapping criteria, admissions at 40 American hospitals to select 117 of the and interobserver variation for subjective criteria. 3,22 537 patients with a history of cirrhosis who were ventiIn addition, important prognostic factors unrelated to lated on ICU day 1, a group known to have a high mortality rate. We then calculated each patient's probability of hepatic function, e.g., measures of renal function, 23,24 hospital death on ICU days 1 through 7, using seven arterial pressure, 25 and study entry time, 26 are not inpreviously validated multivariate equations. Hospital cluded. Because of these limitations, we examined the mortality was 63% for the 117 study patients. The most usefulness of APACHE III (Acute Physiology, Age, and important determinants of risk for hospital death on Chronic Health Evaluation), a physiologically based ICU day 1 were the acute physiology score of APACHE prognostic system, 27 in assessing prognosis for groups III, ICU admission diagnosis, and operative status. Daily of intensive care unit (ICU) admissions with cirrhosis. changes in the acute physiology score caused a rise or ICU admission for patients with cirrhosis has prefall in the probability of hospital mortality and was useviously been recognized to result in low survival ful in assessing individual response to therapy. APACHE III accurately risk stratifies critically ill patients with rates. [28][29][30][31] Poor outcomes are common for all ICU pacirrhosis because it accounts for many of the factors tients with multiple organ system dysfunction or failknown to influence prognosis. This capability can be ure, 32-34 but survival is particularly poor among individused to assess severity of illness and risk-stratify pa-uals with cirrhosis who develop extrahepatic organ tients with cirrhosis during clinical trials. Daily prog-system failure. [35][36][37][38][39][40] For example, hospital mortality nostic estimates based on physiological changes over ranged from 89% to 95% in three studies involving 220 time reflect patient response and can help physicians to nonoperative ICU admissions with cirrhosis who also poor outcome results, we...

Prognostic scores in cirrhotic patients admitted to a gastroenterology intensive care unit

“…These findings support the importance of evaluating the performance of a predictive model not only in terms of its discriminative capacity but also its calibration. If, as in some studies (13,17,36,38), we had based the evaluation on discriminative ability alone, we would say that the SAPS II and CPT scores had the best performance. Nevertheless, we found that the best calibration results were obtained by the SOFA and MELD scores.…”

“…This is particularly relevant in cirrhotic patients, owing to the exponential increase in the incidence of this condition and the limited ICU resources (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) Our study assessed, to our knowledge for the first time, the accuracy of prognostic scores in cirrhotic patients admitted to a GICU. In our series, all the tested scores displayed good discrimination and calibration.…”

“…The incidence of liver cirrhosis is increasing exponentially and cirrhotic patients admitted to ICUs have high mortality rates and a high rate of consumption of resources (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18). Furthermore, a significant percentage (36.7%) of the total cost of ICU care for cirrhotic patients is spent on those who do not survive (11,16,19).…”

“…These results are somewhat unsurprising if we bear in mind that the prognosis of acutely ill patients with cirrhosis is influenced not only by the severity of hepatic insufficiency but mainly by the dysfunction of other organ systems and that cirrhotics admitted to ICUs often have extrahepatic organ dysfunction and die of multiple organ failure (12)(13)(14)(34)(35)(36)(37)(38)(39).…”

Liver transplantation

“…137 Patients with severe chronic liver failure who require intubation have an extremely poor prognosis, with reported hospital mortality rates of 90% to 95%. 141 Patients with CTP scores greater than 10 who have evidence of advanced multisystem disease have the least chance of surviving. Although the majority of these patients will otherwise die, futile attempts at transplantation add greatly to the cost of the surgery and further diminish the limited supply of donor organs for more appropriate candidates.…”