Elsevier

Journal of Hepatology

Volume 60, Issue 3, March 2014, Pages 570-578
Journal of Hepatology

Research Article
Outcome of patients with cirrhosis requiring mechanical ventilation in ICU

https://doi.org/10.1016/j.jhep.2013.11.012Get rights and content

Introduction

Mortality rate of patients with cirrhosis admitted to the intensive care unit (ICU) and requiring mechanical ventilation varies between 60 and 91%. The aim of our study is to assess the prognosis of these patients, their 1-year outcome and to analyze predictive factors of long-term mortality.

Methods

From May 2005 to May 2011, we studied 246 consecutive patients with cirrhosis requiring mechanical ventilation either at admission or during their ICU stay.

Results

Alcohol was the most common etiology of the cirrhosis (69%). Bleeding related to portal hypertension (30%) and severe sepsis (33%) were the most common reasons for admission. ICU and hospital mortality were respectively 65.9% and 70.3%. Prognostic severity scores, the need for other organ support therapy, infection, and total bilirubin value at ICU admission were significantly associated with ICU mortality.

Eighty-four patients (34.1%) were discharged from the ICU. Among these patients, the one-year survival was only of 32%. Logistic regression analysis, using survival at one year as the endpoint, identified two independent risk factors: the length of ventilation (odds ratio [OR] = 1.1; 95% CI, 1.0–1.2; p = 0.02) and total bilirubin at ICU discharge (OR = 1.3; 95% CI, 1.1–1.5; p = 0.006).

Conclusion

Patients with cirrhosis admitted to the liver ICU and who required mechanical ventilation have a poor prognosis with a 1-year mortality of 89%. At ICU discharge, a total bilirubin level higher than 64.5 μmol/L and length of ventilation higher than 9 days could help the hepatologists to identify patients at risk of death in the year following the ICU discharge.

Introduction

The number of patients with liver cirrhosis is increasing and is responsible for approximately 25,000 deaths per year in the United States [1]. It is related to the increase of alcohol related liver disease, of the non-alcoholic fatty liver disease, and of viral hepatitis. In the main situation, this population of patients, with previously compensated cirrhosis, develops acute deterioration revealing their illness. Variceal bleeding, ascites, hepato-renal syndrome, spontaneous bacterial peritonitis and sepsis are the main complications of patients with cirrhosis that would require admission to an Intensive Care Unit (ICU) to optimize management. The outcome of patients with liver cirrhosis in ICU has been widely studied [2], [3], [4], [5], [6], [7], [8]. We know that the requirement for ICU admission, whatever the reasons, is associated with high mortality rates ranging from 36% to 86% [2], [3], [4], [5]. This mortality is significantly related to the number of organ supports during the ICU stay [6], [9], [10], [11], [12]. These studies do not specifically address the question of whether there is a difference between patients with respiratory failure and those with other organ failures.

In recent studies, mechanical ventilation has been identified as an independent factor related to ICU mortality [6], [8]. The decision to intervene aggressively and to use invasive ventilation is frequently questioned in individual patients with cirrhosis. In this subgroup of patients requiring mechanical ventilation, mortality rates reported in the literature range from 59% to 93% [2], [13], [14]. This high mortality rate exceeds the threshold many physicians would use to withhold ICU care for other diseases [15]. In addition, the need of ventilation is associated with higher costs of stays in patients with cirrhosis admitted in ICU [6]. Thus, such a decision to use mechanical ventilation in patients with cirrhosis must be made bearing in mind both the possibility of cure (by liver transplantation for example) and a not too bad long-term survival of patients discharged from the ICU. To identify patients in whom aggressive treatment may offer recovery or those who may benefit from organ support, i.e., as mechanical ventilation, has always been a challenge for intensivists and hepatologists.

The main aim of this prospective study was to evaluate the prognosis of patients with cirrhosis requiring mechanical ventilation during their ICU stay, and to know whether the severity of chronic liver disease or the severity of the acute pulmonary illness or both might determine their outcome.

Section snippets

Study design

This prospective cohort study was performed in the Liver Intensive Care Unit (15 beds) at Paul Brousse University Hospital. This is a tertiary referral unit that has been highly specialized in liver diseases since 1970 with a liver transplantation program. The unit is run by hepatologists, intensivists, and liver surgeons. We screened all patients with cirrhosis hospitalized in the ICU and aged over 18 years. The diagnosis of cirrhosis was based on previous liver biopsy findings or a composite

Patient’s characteristics

From May 2005 to May 2011, two hundred and forty six patients were enrolled in the present study (Fig. 1). The characteristics of the patients included are shown in Table 1. The median age was 56.5 ± 10.3 years; 75% were men and the etiology of the liver disease was most frequently alcohol-related (69%). Among the 170 patients with alcoholic cirrhosis, 19 patients (7.7%) had a histologically proven severe acute alcoholic hepatitis (Maddrey score >32) resistant to corticosteroid therapy. Seven

Discussion

In this large study evaluating patients admitted to our liver ICU during 6 years, we demonstrated that mechanical ventilation in ICU for patients with cirrhosis is associated with a high ICU mortality and a high mortality at one-year. Among the ICU survivors, we observed that a MELD score and bilirubin at ICU discharge higher than 21.5 and 64.5 μmol/L respectively and mechanical ventilation during the ICU stay for more than 9 days are risk factors of death in the year following the ICU discharge.

Conflict of interest

The authors who have taken part in this study declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.

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