Cirrhosis, Alcohol and the ITU

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Cirrhosis, Alcohol and the ITU

• Dr Allister J Grant
• Consultant Hepatologist
• Leicester Royal Infirmary
• http//hepatologist.eu

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The 4 Stages of Life
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Mortality from Cirrhosis

• Total recorded alcohol consumption doubled
  between 1960 and 2002
• 104 increase in Scotland between 1987-1991 and
  1997-2001 in men
• Mortality in women increased 46 in Scotland and
  44 in England

Lancet 2006 367 52-6
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Alcohol Related Deaths in EW 1991-2004
http//www.statistics.gov.uk/cci/nugget.asp?id109
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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
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Leicester City
Local alcohol profiles for England NWPHO 2006
http//www.nwph.net/alcohol/lape/
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ANARP 2004
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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

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Survival of Cirrhotic Patients Admitted to ITU
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Predictors of Outcome

• Liver specific Scoring Systems
• Meld/Peld
• Child Pugh
• Glasgow acute alcoholic hepatitis score
• Critical Care scoring Systems
• Apache II/III
• SOFA

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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

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Meld Score

• MELD Score Listing Status Comments
• lt24 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
• 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
  lt7 days (highest priority for liver
  transplantation).
•  

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Child-Pugh classification of liver failure

• No of points 1 2 3
• Bilirubin (µmol/l) lt34 34-51 gt51
• Albumin (g/l) gt35 28-35 lt28
• Prothrombin time lt3 3-10 gt10
• Ascites None Slight Moderate to severe
• Encephalopathy None Slight Moderate to severe
• Grade A5-6 points, grade B7-9 points, grade
  C10-15 points.

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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

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Sequential Organ Failure Assessment (SOFA) Score
Vincent et al ICM 199622707-710
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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 gt 1.5 mg/dl (gt133?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 3373-79
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• 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

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• Conclusion
• The results indicate that, of the three models,
  Child-Pugh 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.

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Survival After Admission to ICU
Chest 2004 Vol. 126, 51598-1603

• 420 patients non transplant candidates admitted
  to a medical ICU
• Mortality with 3 risk factors
• Vasopressors
• Jaundice (clinical)
• Apache III score gt90
• 92 one month mortality vs 11 with no risk
  factors

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Comparison of APACHE II, Child-Pugh Score and
SOFA in assessing prognosis after 24 hours in
ITUHepatology 2001 34225-261

• 143 medical ICU patients
• Assessed with the above prognostic indices
• Readmissions excluded
• Cirrhotics with known cancer were excluded

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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
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Sequential Organ Failure Assessment (SOFA) Score
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Predicted Hospital Mortality in 143 Cirrhotic
Patients on their First Day in ICU
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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

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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

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Results

• 763 patient admission episodes
• 105 excluded due to being elective admissions
• Further 95 were re-admission episodes
• 563 first admission episodes analysed

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Patient characteristics on ITU admission
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Organ Support
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ITU Survival/Non Survival
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ITU Survival/Non Survival
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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

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EXAMPLES
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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)

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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

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• Difficult decisions
• No compulsion to treat if futile
• Communication gap with relatives
• Clear plans at early stage of treatment
• Realistic assessment of prognosis

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