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

Gibbs, Jeffrey T.; Louissaint, Jeremy; Tapper, Elliot B.

doi:10.1007/s10620-022-07400-3

Cited by 6 publications

(5 citation statements)

References 17 publications

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“…The aOR for mechanical ventilation was approximately 3, an effect size that is clinically meaningful for a study that excluded patients who have the highest risk for in-hospital death (i.e., those with shock and respiratory failure). The mortality rate for ventilated patients with hepatic encephalopathy in our study was comparable with rates cited in other recent studies and additional predictors of mortality in our multivariable models, including ascites and acute kidney injury, are well-established prognostic factors among patients with cirrhosis, suggesting that our cohort is similar to external cohorts [9,20,21]. Although the association between chronic kidney disease and decreased mortality was unexpected, a post-hoc sensitivity analysis suggested that this finding may be partially explained by the fact that a number of these patients received hemodialysis, an intervention that can be used to treat hepatic encephalopathy and may have thus facilitated clinical improvement.…”

Section: Discussionsupporting

confidence: 88%

“…Among those with toxic-metabolic encephalopathies, patients with decompensated cirrhosis are especially vulnerable to the risks of mechanical ventilation with in-hospital mortality among this subset of patients exceeding 50% [9,10]. This is a consequence of factors such as impaired immunity, altered drug metabolism, circulatory dysfunction, and sarcopenia [11].…”

Section: Introductionmentioning

confidence: 99%

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

Saffo¹,

Garcia‐Tsao²

2022

Acute Crit Care

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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.

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Section: Discussionsupporting

confidence: 88%

Section: Introductionmentioning

confidence: 99%

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

Saffo¹,

Garcia‐Tsao²

2022

Acute Crit Care

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“…It is important to note that this population is particularly susceptible to complications of intubation and ventilation including aspiration, nosocomial pneumonia, atelectasis, effusion, and bleeding. Common reasons for intubation include airway protection in the setting of West Haven grade 4 HE, respiratory or cardiovascular failure, or necessary invasive procedures 96 . Intubation for cardiopulmonary failure in particular carries a poor prognosis.…”

Section: Pulmonarymentioning

confidence: 99%

“…Common reasons for intubation include airway protection in the setting of West Haven grade 4 HE, respiratory or cardiovascular failure, or necessary invasive procedures. 96 Intubation for cardiopulmonary failure in particular carries a poor prognosis. The decision to pursue intubation must be carefully weighed.…”

Section: Pulmonarymentioning

confidence: 99%

“…5 In patients with cirrhosis requiring MV for HE, a retrospective cohort study found that administration of rifaximin within 24 hours of intubation improved the rate of extubation. 96 Prolonged translaryngeal intubation should be avoided, and percutaneous tracheostomy can be performed with minimal risk even in the presence of coagulopathy. 99 Tracheostomy should be considered within the first 7 to 10 days of intubation, and conversations with patients and care teams should take place earlier.…”

Section: Pulmonarymentioning

confidence: 99%

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Cirrhosis Management in the Intensive Care Unit

2023

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Patients with cirrhosis frequently require admission to the intensive care unit as complications arise in the course of their disease. These admissions are associated with high short- and long-term morbidity and mortality. Thus, understanding and characterizing complications and unique needs of patients with cirrhosis and acute-on-chronic liver failure helps providers identify appropriate level of care and evidence-based treatments. While there is no widely accepted critical care admission criteria for patients with cirrhosis, the presence of organ failure and primary or nosocomial infections are associated with particularly high in-hospital mortality. Optimal management of patients with cirrhosis in the critical care setting requires a system-based approach that acknowledges deviations from canonical pathophysiology. In this review we discuss appropriate considerations and evidence-based practices for the general care of patients with cirrhosis and critical illness.

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SOFA in sepsis: with or without GCS

Wang,

Ma,

Zhou

et al. 2024

Eur J Med Res

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Purpose Sepsis is a global public health burden. The sequential organ failure assessment (SOFA) is the most commonly used scoring system for diagnosing sepsis and assessing severity. Due to the widespread use of endotracheal intubation and sedative medications in sepsis, the accuracy of the Glasgow Coma Score (GCS) is the lowest in SOFA. We designed this multicenter, cross-sectional study to investigate the predictive efficiency of SOFA with or without GCS on ICU mortality in patients with sepsis. Methods First, 3048 patients with sepsis admitted to Peking Union Medical College Hospital (PUMCH) were enrolled in this survey. The data were collected from June 8, 2013 to October 12, 2022. Second, 18,108 patients with sepsis in the eICU database were enrolled. Third, 2397 septic patients with respiratory system ≥ 3 points in SOFA in the eICU database were included. We investigated the predictive efficiency of SOFA with or without GCS on ICU mortality in patients with sepsis in various ICUs of PUMCH, and then we validated the results in the eICU database. Main results In data of ICUs in PUMCH, the predictive efficiency of SOFA without GCS (AUROC [95% CI], 24 h, 0.724 [0.688, 0.760], 48 h, 0.734 [0.699, 0.769], 72 h, 0.748 [0.713, 0.783], 168 h, 0.781 [0.747, 0.815]) was higher than that of SOFA with GCS (AUROC [95% CI], 24 h, 0.708 [0.672, 0.744], 48 h, 0.721 [0.685, 0.757], 72 h, 0.735 [0.700, 0.757], 168 h, 0.770 [0.736, 0.804]) on ICU mortality in patients with sepsis, and the difference was statistically significant (P value, 24 h, 0.001, 48 h, 0.003, 72 h, 0.004, 168 h, 0.005). In septic patients with respiratory system ≥ 3 points in SOFA in the eICU database, although the difference was not statistically significant (P value, 24 h, 0.148, 48 h, 0.178, 72 h, 0.132, 168 h, 0.790), SOFA without GCS (AUROC [95% CI], 24 h, 0.601 [0.576, 0.626], 48 h, 0.625 [0.601, 0.649], 72 h, 0.639 [0.615, 0.663], 168 h, 0.653 [0.629, 0.677]) had a higher predictive efficiency on ICU mortality than SOFA with GCS (AUROC [95% CI], 24 h, 0.591 [0.566, 0.616], 48 h, 0.616 [0.592, 0.640], 72 h, 0.628 [0.604, 0.652], 168 h, 0.651 [0.627, 0.675]). Conclusions In severe sepsis, it is realistic and feasible to discontinue the routine GCS for SOFA in patients with a respiratory system ≥ 3 points, and even better predict ICU mortality.

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

Cited by 6 publications

References 17 publications

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

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

Cirrhosis Management in the Intensive Care Unit

SOFA in sepsis: with or without GCS

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