Transcript Cirrhosis, Alcohol and the ITU

Cirrhosis, Alcohol and the ITU
Dr Allister J Grant
Consultant Hepatologist
Leicester Royal Infirmary
http://hepatologist.eu
The 4 Stages of Life
Mortality from Cirrhosis
• Total recorded alcohol consumption doubled
between 1960 and 2002
• 104% increase in Scotland between 19871991 and 1997-2001 in men
• Mortality in women increased 46% in Scotland
and 44% in England
Lancet 2006; 367: 52-6
Alcohol Related Deaths in E&W 1991-2004
http://www.statistics.gov.uk/cci/nugget.asp?id=1091
Alcohol in the East Midlands
•
In 2004 the General Household Survey found that 23% of men and 11% of women
in the East Midlands reported binge drinking on at least one day in the previous
week.
•
Although knowledge of alcohol units is increasing only 13% of those who had
heard of units used them to keep a check on how many units they drank.
•
There were approximately 30,000 alcohol-related hospital admissions during
2004/05 in the East Midlands.
•
Alcohol is a factor in an estimated 2,000 deaths annually in the East Midlands.
•
The mortality rate due to alcohol related diseases varies throughout the region
with more than a two fold difference across local authorities.
•
Mortality rates from chronic liver disease have more than doubled in the last ten
years.
www.empho.org.uk
Leicester City
Local alcohol profiles for England –NWPHO 2006
http://www.nwph.net/alcohol/lape/
ANARP 2004
Cirrhosis and the ITU-Background
• 4000 patients died in UK from
complications of cirrhosis in the year 2000
– Incidence of cirrhosis is rising dramatically
– Increasing numbers of patients will present
with cirrhosis and organ dysfunction
• Patients are frequently denied access to ITU
on basis of presumed futility
– “Prognostic pessimism”
Survival of Cirrhotic Patients
Admitted to ITU
Survival
Author
Number
ITU
Hospital
Cholongitas et al 2006 (UK)
312
-
35%
Aggarwal A et al 2001 (USA)
240
63%
51%
Wehler et al 2001 (Germany)
143
64%
54%
Arabi et al 2004 (Saudi Arabia)
129
-
26%
Zimmerman et al 1996 (USA)
117
-
37%
Tsai et al 2003 (Taiwan)
111
-
35%
Rabe et al 2004 (Germany)
76
41%
-
Predictors of Outcome
• Liver specific Scoring Systems
o Meld/Peld
o Child Pugh
o Glasgow acute alcoholic hepatitis score
• Critical Care scoring Systems
o Apache II/III
o SOFA
Meld Score
• MELD Score = 10 {0.957 Ln(Scr) + 0.378
Ln(Tbil) + 1.12 Ln(INR) + 0.643}
• Used in organ allocation on the transplant list
in USA/UK
Meld Score
•
MELD Score
Listing Status
•
<24
3
CPT score = 7 to 9; too early for
transplantation
•
24 – 29
2b
CPT score ≥10; end-stage chronic
liver disease; severely ill pt, not
requiring hospitalization
•
≥30
2a
CPT score ≥10; end-stage chronic
liver disease; severely ill pt,
hospitalized in an ICU
Comments
*Notes:
Assuming pts meet listing criteria (appropriate cadidates for liver transplantation)
Criteria for status 1 remain unchanges; acute liver failure/disease with estimated survival of <7 days (highest
priority for liver transplantation).
Child-Pugh classification of liver failure
• No of points
1
2
•
•
•
•
•
<34
>35
<3
None
None
34-51
28-35
3-10
Slight
Slight
Bilirubin (µmol/l)
Albumin (g/l)
Prothrombin time
Ascites
Encephalopathy
3
>51
<28
>10
Moderate to severe
Moderate to severe
• Grade A=5-6 points, grade B=7-9 points, grade C=10-15 points.
Apache Scores
• Used to estimate group mortality and severity of illness for
ITU patients
• Combination of acute physiological scores and chronic health
evaluation points
• Apache II used as national standard but lacks bilirubin and
albumin found in Apache III
• ?Applicable to ward environment as all studies use APACHE on
1st day of ITU stay
• Scores only valid when applied to a cohort
Sequential Organ Failure Assessment (SOFA) Score
Vincent et al ICM 1996;22:707-710
Predictors of Outcome
• 54 consecutive patients, overall mortality 43%
– Apache II score significant predictor of outcome
– Child Pugh scores not predictive
Univariate analysis significant predictors:
– Requirement and length of mechanical ventilation
– Pulmonary infiltrates
– GI haemorrhages
– Serum creatinine > 1.5 mg/dl (>133mol/L)
– Infections
Mortality in patients with cirrhosis caused by alcohol was significantly lower than
that in patients with liver disease not caused by alcohol (P = 0.01).
Singh N et al. Outcome of patients with cirrhosis requiring intensive care unit support
; prospective assessment of predictors of mortality. J Gastroenterology 1998; 33:73-79
A comparison of Child-Pugh, APACHE II and APACHE
III scoring systems in predicting hospital mortality of
patients with liver cirrhosis
Constantinos Chatzicostas, Maria Roussomoustakaki, Georgios Notas,
Ioannis G Vlachonikolis, Demetrios Samonakis, John Romanos,
Emmanouel Vardas, and Elias A Kouroumalis
Conclusion
The results indicate that, of the three models, ChildPugh score had the least statistically significant
discrepancy between predicted and observed
mortality across the strata of increasing predicting
mortality. This supports the hypothesis that APACHE
scores do not work accurately outside ICU settings.
Survival After Admission to ICU
Chest 2004 Vol. 126, 5;1598-1603
• 420 patients – non transplant candidates
admitted to a medical ICU
• Mortality with 3 risk factors
– Vasopressors
– Jaundice (clinical)
– Apache III score >90
92% one month mortality vs 11% with no risk factors
Comparison of APACHE II, Child-Pugh Score and SOFA
in assessing prognosis after 24 hours in ITU
Hepatology 2001 34:225-261
• 143 medical ICU patients
• Assessed with the above prognostic indices
• Readmissions excluded
• Cirrhotics with known cancer were excluded
Mortality Rates in Cirrhotic Patients Depending on the
Number of Failing Organs
Organ failure defined as a SOFA score of 3 or more for each respective organ
Hepatology. 2001, 34,2: 255-261
Sequential Organ Failure Assessment (SOFA) Score
Predicted Hospital Mortality in 143 Cirrhotic Patients
on their First Day in ICU
Defining the impact of organ
dysfunction in cirrhosis:
Survival at a cost?
DL Shawcross, MJ Austin, RD Abeles, M McPhail, A
Yeoman, N Taylor, AJ Portal, W Bernal, G Auzinger,
E Sizer, JA Wendon.
Institute of Liver Studies
BSG Presentation 2008
Methods
• Critical Illness scoring systems:
– SOFA, APACHE II
• Liver specific scores:
– MELD, Child-Pugh
• Use of vasopressors, invasive ventilation
and renal replacement therapy (RRT)
recorded
• Therapeutic Intervention Scoring System
(TISS) points calculated for each admission
– 1 TISS point = £48
Results
• 763 patient admission episodes
– 105 excluded due to being elective admissions
– Further 95 were re-admission episodes
• 563 first admission episodes analysed
Patient characteristics on ITU admission
Number
563
Age
50 (16-87)
Male
348 (62%)
Aetiology
Alcohol
Viral hepatitis
Autoimmune
Cryptogenic
Other
263 (47%)
98 (17%)
73 (13%)
48 (9%)
81 (14%)
Reason for admission Variceal Bleed
Non Variceal Bleed
196 (35%)
367 (65%)
Scoring System
12 (11-13)
25 (14-34)
22 (16-28)
11 (8-13)
Child-Pugh
MELD
APACHE II
SOFA
Organ Support
Organ Support
Day 1
At any time
Number Requiring Ventilation
349/563 (62%)
405/563 (72%)
Number Requiring Vasopressors
202/563 (36%)
229/563 (41%)
Number Requiring RRT
102/563 (18%)
273/563 (49%)
ITU Survival/Non Survival
Survivors
Non-survivors
p value
Number
307 (55%)
256 (45%)
-
Age
49 (30-68)
51 (34-68)
ns
196:111
152:104
ns
Alcohol
Other
146/263 (56%)
117/263 (44%)
ns
161/300 (54%)
139/300 (46%)
Variceal Bleed
Non Variceal
139/196 (71%)
168/367 (46%)
57/196 (29%)
199/367 (54%)
Male : Female
Aetiology
Reason for
Admission
<0.0001
ITU Survival/Non Survival
Survivors
Non Survivors
p value
Child-Pugh score
11 (10-12)
13 (11-13)
<0.0001
MELD
17 (10-28)
31 (23-37)
<0.0001
APACHE II
17 (14-23)
27 (21-31)
<0.0001
9 (7-11)
13 (10-16)
<0.0001
Requirement for RRT
27%
73%
<0.0001
Requirement for Vasopressors
20%
80%
<0.0001
Requirement for Ventilation
44 %
56%
<0.0001
SOFA
Conclusion
• ITU admission not futile in cirrhotic patients with
organ dysfunction
–
–
–
–
55% survive ITU, 41% to hospital discharge
Aetiology not related to outcome
Variceal bleeders have better survival
Requirement for renal replacement therapy and/or
vasopressors strongly linked with mortality
• Outcomes Improving
– Earlier admission?
– Early intubation?
• Admit early and assess response
EXAMPLES
Which patients will not benefit?
• Established multi-organ failure (3 organ)
• Chronic inexorable decline “end stage disease”
• Patients with high Apache III scores
• Patients where there is no hope of long term
survival (transplantation not being an option)
What about High Dependency Care?
• Limited resource
• Outreach teams for critical care to support
ward staff and junior medical staff
• Targeted at those who will benefit most
• Early plan needs to made by Consultant
Hepatologist/Gastroenterologist and
Intensivists
•
•
•
•
•
Difficult decisions
No compulsion to treat if futile
Communication gap with relatives
Clear plans at early stage of treatment
Realistic assessment of prognosis