Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Liver disease in ICU – when to stop? by Julia Wendon

977 views

Published on

Liver disease in ICU – when to stop? by Julia Wendon

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Liver disease in ICU – when to stop? by Julia Wendon

  1. 1. AoCLF patients – should we admit to critical care services and when to stop • Prognostic models • Design • Utility • Bottom of the bed assessment • frailty assessment • Response or lack of response to Rx • Why admit • What does CC provide • Ethics • Societal vs individual
  2. 2. Cirrhosis / AoCLD • Critically ill Cirrhotics / AoCLF – Variceal bleed – Metabolic disarray ± sepsis – Alcoholic hepatitis – Liver hit : Hepatocellular cancer, portal vein thrombosis, viral infection, DILI – Inexorable deterioration of liver function – not AoCLF • End organ dysfunctions – Brain – Cardiac and vascular – Renal – Respiratory
  3. 3. Possible points of CC referral Is this new disease Is this a homogoenous population What is AoCLF ? Asian view minor fibrosis/ fat + viral, DILI European / USA view varices, sepsis, paracentesis
  4. 4. Braveno IV status classification of cirrhosis STAGE 1. NO VARICES NO ASCITES STAGE 2. VARICES NO ASCITES STAGE 3. ASCITES VARICES STAGE 3. BLEEDING +/- ASCITES 1-year Outcome Probabilities DEATH J Hepatology 2006;44:217-231 1% 3.4% 20% 57%
  5. 5. Lancet online September 28, 2015
  6. 6. Why admit to ITU • Firstly will the patient may benefit from CC interventions • What does CC provide – Avoids death from specific organ failures • MAP, airway, hypoxia, renal – Provides time for organ recovery – Provides excellent nursing care – Provides communication – Provides attention to detail • What does CC not provide – Magic
  7. 7. Alcoholic hepatitis Lille score Age Renal INR Bilirubin Albumin Delta Bilirubin Aliment Pharmacol Ther 2014; 39: 721–732, Burroughs Comparison of 9 scores : no difference in AUC 3.19-0.101*(age)+0.147*(alb day 0) +0.0165*(change in Bili)- 0.206*(renal insufficiency {0/1:creat < or > 115 µmol/L)-0.0065 (Day 0 Bili)
  8. 8. 5 days NAC Rx Mortality at 1 mnth 8 vs 24%p=0.006 3 mnth 22 vs 34 % p=0.06 6 mnth 27 vs 38% p=0.07 Less HRF 9 vs 22 % p= 0.02 Decreased infection 42 vs 19% P=0.001
  9. 9. Philippe Mathurin, JAMA. 2013;310(10):1033-1041
  10. 10. Increased creatinine and PT also associated with IA X 2 candida galbrata X 8 PCP 6 proven 8 probable 1 possible IA by 28 days CMV Screen galactomanan >0.45 Journal of Hepatology 2014 vol. 60 j 267–274Gustot
  11. 11. Na, brain and outcome Critical Care 2014, 18:700 Increased ITU stay and mortality
  12. 12. • Resuscitation : Airway • Coagulation support • Diagnostic endoscopy + • Therapy • Vasoactive drugs • Endoscopic therapy • banding and glue • Failed drugs + OGD • Balloon tamponade • TIPS Outcome : infection, active bleeding, HCC,CP score, renal failure Terlipressin used in the community in GI bleed at risk varices : improved outcome and cost Int Care Med 1999
  13. 13. …………….
  14. 14. Child Pugh C 10-13 Child Pugh B 7-9 : if active bleeding at OGD CP > 13 excluded All Rx with vasoactive drug and endoscopic Rx Randomized within 24 hours TIPS within 72 hours
  15. 15. 4 units blood in initial 24 hours and active bleeding Also impact on 6 week mortality 5 day survival
  16. 16. CXR – that wasn’t seen before the OGD!
  17. 17. Alastair J. O’Brien Intensive Care Med (2012) 38:991–1000
  18. 18. Definition of organ failure Modified SOFA score for Cirrhosis (The SOFA-CLIF SCORE) Organ/system 0 1 2 3 4 Liver (Bilirubin, mg/dL) <1.2 ≥1.2 - ≤1.9 ≥2 - ≤5.9 ≥6 - <12 ≥12 Kidney (Creatinine (mg/dL) <1.2 ≥1.2 - ≤ 1.9 ≥2 - <3.5 ≥3.5 - <5 ≥5 or use of renal-replacement therapy Cerebral (HE grade) No HE 1 2 3 4 Coagulation (INR) <1.1 ≥1.1 – <1.25 ≥1.25 - <1.5 ≥1.5 – <2.5 ≥2.5 or Platelets20x109/L Circulation (MAP mm Hg) ≥70 <70 Dopamine ≤5 or Dobutamine or Terlipressin Dopamine >5 or E ≤ 0.1 or NE ≤ 0.1 Dopamine >15 or E > 0.1 or NE > 0.1 Lungs PaO/FiO2: or SpO2/FiO2 >400 >512 >300 - ≤400 >357 - ≤512 >200 - ≤300 >214 - ≤357 >100 - ≤200 >8 - ≤214 ≤100 ≤89 GASTROENTEROLOGY 2013;144:1426–1437
  19. 19. • 1343 enrolled into study • 303 had AoCLF at the time of study commencement • 112 developed AoCLF during the study period • 928 never developed ACLF PREVALENCE (n= 1342) MORTALITY (n=1287) Organ failure 32.9% 26.9% No Organ failure 67.1% 4.4% 1 Organ failure n=281 21. 4% 14.6% 2 Organ failures n=107 8.0% 32.0% 3 Organ failures n=28 2.1% 68.0% > 3 Organ failures n=19 1.4% 88.9%
  20. 20. GASTROENTEROLOGY 2013;144:1426–1437
  21. 21. Acute on chronic liver failure: outcome of cirrhotic patients admitted to the ICU Aggrawal A Chest 2001 Cholongitas E Aliment Pharm Ther 2006 Levesque E J Hepatol 2012 Shawcross D J Hepatol 2012 n 420 312 377 563 SOFA / 11 9.4 11 MELD / 24 24.9 25 Child-Pugh 9.6 11 10.5 12 ICU mortality 36.6% 65.3% ICU+ 6 weeks mortality 34.7% 51% Hospital mortality 49% 43% 59%
  22. 22. Acute on chronic liver failure: Other factors and prognosis Levesque E et al. J Hepatology 2012, n = 377 Source : Chest : HE Ascites Blood Urine MDR organisms
  23. 23. Acute on chronic liver failure: Prognostication based on scores Levesque E et al. J Hepatology 2012, n =377
  24. 24. Adjusted for severity of illness Significant improvement Greatest for those with Varices and 3 OF 50% survival (hospital) Non- variceal 3 OF : 25% survival McPhail 2015 Is AoCLF one disease ???
  25. 25. Lactate > 1.8 at day 3 or 7 AUC 0.78
  26. 26. For patients with APACHE II scores greater or equal to 20 (n = 509; 52%), there was a significant improvement in survival (20% to 47%; P < .001) 58% ITU survival 48% hospital survival , For patients with low APACHE II scores ( <20; n =462; 48%), there was a small but not statistically significant increase in survival over the study period (p=0.056) 50% in receipt of RRT SOFA 11 CLIFF SOFA 11 APACHE II 22 MELD 26
  27. 27. • A SOFA/CLIF-SOFA score of greater than 13 on Day 1 • 90% mortality rate • SOFA scores greater than 13 on Day 3 and 7 • 89% and 90% mortality rates respectively • Lactate level greater than 4 mmol/L on Day 1 • 81% mortality rate • Lactate level greater than 4 mmol/L on day 3 and 7 • 91% mortality rate and 88% mortality respectively • The absolute SOFA score on day 3 was a better predictor of mortality than change in score. • Delta SOFA score changes • Increase from day 1 : mortality 51% • Unchanged : mortality of 42% • Decrease after Day 1 : mortality was 28%. Mark J. W. McPhail Clinical Gastroenterology and Hepatology 2014
  28. 28. The Royal Free Hospital Score: A Calibrated Prognostic Model for Patients With Cirrhosis Admitted to Intensive Care Unit. Comparison With Current Models and CLIF- SOFA Score Am J Gastroenterol. 2014 Feb 4. Burroughs AK
  29. 29. Acute on chronic liver failure: Prognostication based on number of organ failures The American Journal of GASTROENTEROLOGY 2014 Theocharidou 3 OF in CLIF data base associated with 89% mortality
  30. 30. Incorporation of age and wbc : CLIFF C score CLIF – C organ failure score Jalan et al Journal of Hepatology 2014 vol. 61 j 1038–1047
  31. 31. AUC 0.76 vs 0.72 for CLIFF SOFA Journal of Hepatology 2014 vol. 61 j 1038–1047
  32. 32. Fixing specificity at 95% and estimating sensitivity (bootstrap method) A cut-off value of greater than 14 for CLIF-SOFA gives a sensitivity of 32% (26%– 40%) A cut-off of greater than 12 for SOFA gives a sensitivity of 33 (26– 39) Suggests neither score : SOFA or CLIFF SOFA provide an accurate indicator of futility. Mark J. W. McPhail Clinical Gastroenterology and Hepatology 2015 Can we predict “Futility”
  33. 33. Tx group : SOFA on admission, 48 hours and LT were 13,13 and 14 – 74% survival at 1 year Died awaiting Tx : SOFA on admission 14 and 17 at 48 hours lactate higher (3.6 vs 2.8) also and also at 48 hours
  34. 34. Case : 50 year old man ALD, occasional drinking but remains in full employment Presents jaundice, oedema, SoB - ?PE Rx clexane - admitted to ward Day 2 : CT-PA negative BUT now Confused ++, malaena observed Intubated for OGD in theatre : no bleeding point seen Extubated - bradycardic, intubated, CPR X 1 cycle In recovery - annuric, acidotic, adrenaline / noradrenaline infusions pH 7.06 pO2 8.6 pCO2 8.2 HCO3 13.6 BE-14 Fi02 0.5 Lactate 2.7 mMol/l Na 135 K 6.8 Urea 30 (N< 7) Creatinine 587 (N < 120) Bilirubin 100 µmol/L (5.8 mg /dl) ALP 56 AST 244 GGT 339 WBC 16.4 Hb 12.4 Plt 73 INR 2.94 APTT 2.02 CRP 190 Child Pugh 6-8 (pre) MELD 27 SOFA 17 CLIFF COF ACLF 3 CLIFF C 70 (91% mortality) Swollen inflammed Leg with area of necrosis
  35. 35. Day 4 Free of pressors Passing urine Fi02 0.4 INR 1.6 Culture negative Rising ASO titre Discharged to ward day 18
  36. 36. Teams make things work, if we don’t try we will never improve julia.wendon@kcl.ac.uk
  37. 37. Mark J. W. McPhail Clinical Gastroenterology and Hepatology 2014
  38. 38. Antimicrobial therapeutic determinants of outcomes from septic shock among patients with cirrhosis Hepatology. 2012 December; 56(6): 2305– 2315 Hospital mortality 75% Median time to antibiotics : 7 hours Each hour delay OR of 1.1 Inappropriate antibiotics OR 9.5
  39. 39. MDR infections 18% overall BUT seen in 4, 18 and 35 % of the groups Efficacy of treatment only 40% in nosocomial sepsis Nosocomial sepsis, recent beta lactams, norfloxacin, previous mdr infections assoc with mdr sepsis mortality of 25% vs 12% for MDR aetiologies : similar for septic shock
  40. 40. Journal of Hepatology 2015 vol. 62 j 816–821
  41. 41. Karvellas Crit Care Med 2010 Vol. 38, No. 1
  42. 42. Tx group : SOFA on admission, 48 hours and LT were 13,13 and 14 – 74% survival at 1 year Died awaiting Tx : SOFA on admission 14 and 17 at 48 hours lactate higher (3.6 vs 2.8) also and also at 48 hours
  43. 43. Hyperacute < 7 days Acute 1 -4 weeks Subacute 4-12 weeks Hperacute + acute HE, cerebral oedema Sub acute jaundice, ascites late HE Acute Liver Failure Primary liver injury Coagulaopthy Encephalopathy No preexisting liver disease
  44. 44. 23 year old 3 weeks malaise AST 6000 INR 6.5 Lactate 15 Grade II Creatinine 350 µmol/L Bilirubin 200 µmol/L (12 mg/dl) NH4 75 µmol/L Scv02 60% norepinephrine Milronine Levosomendin
  45. 45. INR 6.5, temp 41, fitting, rhabodmyolysis, ARF, lactate 6 Review of 19 patients : 80% non Tx survival
  46. 46. Acute on chronic liver failure: Prognostication based on scores Levesque E et al. J Hepatology 2012, n = 377
  47. 47. Jalan et al Journal of Hepatology 2014 vol. 61 j 1038–1047
  48. 48. No organ support 1 day respiratory Sepsis and > 1 day resp support 1 day resp and Renal support Sepsis & resp &renal
  49. 49. 20-40% of patients discharged who had required organ support on admission : 6 month survival of 40%

×