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Published on: January 16, 2019
Prognosis of cirrhotic patients admitted to the general ICU
Gaël Piton1,2, Claire Chaignat3, Mikhael Giabicani4
1Intensive Care Unit, Besançon University Hospital, 25030, Besançon, France. gpiton@chu-besancon.fr.
Insights
Cirrhotic patients in general ICUs have high mortality. A new score using SOFA, INR, and renal replacement therapy predicts outcomes, identifying patients for whom intensive care escalation may not be beneficial.
Area of Science:
- Critical Care Medicine
- Hepatology
- Prognostic Modeling
Background:
- Prognosis for cirrhotic patients in ICUs is generally poor, with most data from liver-specific ICUs.
- Limited data exists on outcomes for cirrhotic patients admitted to general ICUs.
Purpose of the Study:
- To describe the prognosis of cirrhotic patients in a general ICU.
- To identify predictors of mortality in this population.
- To identify patients who may not benefit from intensive care escalation.
Main Methods:
- Retrospective monocentric study of 218 cirrhotic patients admitted to a general ICU (2002-2014).
- Analysis of 28-day and 6-month mortality rates.
- Development and validation of a prognostic model using SOFA score, INR, and renal replacement therapy.
Main Results:
- 28-day and 6-month mortality rates were 53% and 74%, respectively.
- A prognostic score (SOFA ≥ 12, INR ≥ 2.6, renal replacement therapy) predicted 28-day mortality.
- Patients with a score of 4 (16% of cohort) had 91% 28-day and 100% 3-month mortality.
Conclusions:
- Mortality in general ICUs for cirrhotic patients is comparable to liver ICUs.
- A pragmatic score integrating SOFA, INR, and renal replacement therapy accurately predicts mortality.
- This score can help identify patients with extremely poor prognosis, guiding decisions on intensive care escalation, especially when liver transplantation is not an option.
Background:
The prognosis of cirrhotic patients admitted to the ICU is considered to be poor but has been mainly reported in liver ICU. We aimed to describe the prognosis of cirrhotic patients admitted to a general ICU, to assess the predictors of mortality in this population, and, finally, to identify a subgroup of patients in whom intensive care escalation might be discussed.
Results:
We performed a retrospective monocentric study of all cirrhotic patients consecutively admitted between 2002 and 2014 in a general ICU in a regional university hospital. Two hundred and eighteen cirrhotic patients were admitted to the ICU. The 28-day and 6-month mortality rates were 53 and 74 %, respectively. Among the 115 patients who were discharged from ICU, only eight patients underwent liver transplantation, whereas 48 had no clear contraindication. Multivariable analyses on 28-day mortality identified three independent variables, incorporated into a new three-variable prognostic model as follows: SOFA ≥ 12 (OR 4.2 [2.2-8.0]; 2 points), INR ≥ 2.6 (OR 2.5 [1.3-4.8]; 1 point), and renal replacement therapy (OR 2.3 [1.1-5.1]; 1 point). For a value of the score at 4 (16 % of patients), 28-day and 3-month mortality rates were 91 and 100 %, respectively. An external validation of the score among 149 critically ill cirrhotic patients showed a good accuracy for predicting in-ICU mortality.
Conclusions:
Mortality of cirrhotic patients admitted to a general ICU was comparable to that of other studies. A pragmatic score integrating the SOFA score, INR, and the need for extrarenal epuration was strongly associated with mortality. Among the 16 % of patients presenting with score 4 at ICU admission, 100 % died in the 3-month follow-up period. The prognostic evaluation on day 3 remains essential for the majority of patients. However, this score calculable at ICU admission might identify patients in whom the benefit of intensive care escalation should be discussed, in particular when liver transplantation is contraindicated.
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