Associations Between Mean Arterial Pressure and Poor ICU Outcomes in Critically Ill Patients With Cirrhosis: Is 65 The Sweet Spot?

Patidar, Kavish R.; Peng, Jennifer L.; Pike, Francis; Orman, Eric S.; Glick, Mathew; Kettler, Carla; Nephew, Lauren; Desai, Archita P.; Nair, Kavitha; Khan, Babar; Buckley, Caitriona; Machado, Roberto F.; Chalasani, Naga; Ghabril, Marwan

doi:10.1097/ccm.0000000000004442

Cited by 21 publications

(27 citation statements)

References 29 publications

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“…Table 2 describes the liver-related characteristics among the group with cirrhosis. The median baseline MELD and Child-Pugh scores were 23.1 (16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34) and 9 (7)(8)(9)(10)(11)(12), respectively. Additionally, on ICU admission, 70.5% of the group with cirrhosis had ascites, 39.3% had hepatic encephalopathy, and the median INR was 1.7 (1)(2).…”

Section: Resultsmentioning

confidence: 99%

“…[11][12][13] However, a recent study published analyzing the association between time-weighted mean MAPs and mortality suggests that MAPs <65 mm Hg are associated with a significantly increased risk of mortality for patients with cirrhosis within the first 24 hours after ICU admission. 24 Additionally, the Society of Critical Care Medicine suggests targeting a MAP of 65 mm Hg in patients with acute liver failure or ACLF, with concomitant assessment of perfusion. 25 In contrast to patients with low BP, a prospective study that aimed to individualize MAP goals based on baseline hemodynamics showed improved outcomes with increased MAP goals in hypertensive patients in septic shock; however, subsequent studies and pooled analyses failed to confirm these results.…”

Section: Discussionmentioning

confidence: 99%

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Comparison of Vasopressor Duration in Septic Shock Patients With and Without Cirrhosis

2020

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Background Patients with cirrhosis have immune dysfunction, altered inflammatory response, and hemodynamic changes which increase risk of septic shock and potentially prolong management with fluids, vasopressors, and other therapies. Due to limited available guidance, this study aimed to characterize vasopressor use in patients with cirrhosis in relation to patients without cirrhosis in septic shock. Methods This was a retrospective matched cohort analysis of 122 patients admitted to the intensive care unit (ICU) at an academic medical center from January 2015 to November 2017. Patients were grouped based on the presence or absence of cirrhosis and matched based on severity of illness scoring. The primary outcome was vasopressor duration. Secondary comparisons included total vasopressor requirement, length of hospital and ICU stay, in-hospital mortality, change in organ function, and discharge disposition. Results The group with cirrhosis had significantly longer median (interquartile range [IQR]) durations of vasopressor therapy compared with the group without cirrhosis (86.0 [42.0-164.5] vs 39.0 [14.5-82.0] hours; P = 0.003) leading to increased median (IQR) vasopressor exposure (71.7 [15.5-239.5] vs 24.7 [5.3-77.9] mg norepinephrine [NE] equivalents; P = 0.003). No difference was found in in-hospital mortality between groups. However, regression analysis showed vasopressor exposure was associated with in-hospital mortality. Conclusion and Relevance Patients with cirrhosis in septic shock have increased vasopressor durations and overall requirements compared with patients without cirrhosis. Increased durations and requirements is associated with poorer outcomes independent of presence of cirrhosis. Future studies are needed to improve vasopressor treatment strategies and end points utilized in cirrhosis.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Comparison of Vasopressor Duration in Septic Shock Patients With and Without Cirrhosis

2020

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“…Covariates chosen for multivariable modeling were selected a priori due to their clinical significance. These include age, ( 2 , 18 ) admission CLIF‐C score, ( 18 ) admission MELD score, ( 21 , 22 ) presence of infection at time of ICU admission, ( 23 , 24 ) day 1 use of vasopressors, ( 23 , 25 ) and day 1 use of mechanical ventilation. ( 21 , 26 ) Day 1 hemodialysis was not included as a covariate as it was captured in either the CLIF‐C or MELD score.…”

Section: Methodsmentioning

confidence: 99%

Severe Alcohol‐Associated Hepatitis Is Associated With Worse Survival in Critically Ill Patients With Acute on Chronic Liver Failure

et al. 2021

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Differences in mortality between critically ill patients with severe alcohol‐associated hepatitis (sAH) and acute‐on‐chronic liver failure (ACLF) and non‐sAH ACLF (i.e., ACLF not precipitated by sAH) are unknown. Such differences are important, as they may inform on prognosis and optimal timing of liver transplantation (LT). Thus, we aimed to compare short‐term and longer‐term mortality between patients with sAH ACLF and patients with non‐sAH ACLF who were admitted to the intensive care unit. Patients with ACLF admitted from 2016‐2018 at two tertiary care intensive care units were analyzed. SAH was defined by the National Institute on Alcohol Abuse and Alcoholism’s Alcoholic Hepatitis Consortium and Model for End‐Stage Liver Disease score >20. Mortality without LT was compared between sAH ACLF and non‐sAH ACLF using Fine and Gray’s competing‐risks regression. A total of 463 patients with ACLF (18% sAH and 82% non‐sAH) were included. Compared to patients with non‐sAH ACLF, patients with sAH ACLF were younger (49 vs. 56 years; P < 0.001) and had higher admission Model for End‐Stage Liver Disease (MELD) (35 vs. 25; P < 0.001) and Chronic Liver Failure Consortium (CLIF‐C) scores (61 vs. 57; P = 0.002). There were no significant differences between the two groups for vasopressor, mechanical ventilation, and hemodialysis use. The cumulative incidence of death was significantly higher in patients with sAH ACLF compared to patients with non‐sAH ACLF: 30‐day 74.7% versus 45.3%; 90‐day 81.9% versus 57.4%; 180‐day 83.2% versus 63.0% (unadjusted subdistribution hazard ratio [sHR] 1.88 [95% confidence interval (CI) 1.44‐2.46]; P < 0.001). After adjusting for CLIF‐C score and infection in a multivariable competing‐risk model, patients with sAH ACLF had significantly higher risk of death (sHR 1.57 [95% CI 1.20‐2.06]; P = 0.001) compared to patients with non‐sAH ACLF. Conclusion: Critically ill patients with sAH ACLF have worse mortality compared to patients with non‐sAH ACLF. These data may inform prognosis in patients with sAH and ACLF, and early LT referral in potentially eligible patients.

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“…We excluded patients who were diagnosed with AKI in the ICU setting because they may have more profound haemodynamic instability, shock, or respiratory failure that could impact albumin utilisation and AKI recovery. 25…”

Section: Practice Pattern Cohortmentioning

confidence: 99%

“…The median age was 61 (53, 70) years, 60.3% were male, 70.1% were white, median sCr 1.8 (1.3, 2.8) mg/dL, and the median MELD-Na score was 24 (18,29). During the study period, 35% of patients received albumin, ranging from 25% to 40% per year, and the median grams of albumin given during the hospitalization was 50 (25,125). There was a modest 4% annual increase in the odds of albumin use over time (OR 1.04 [95% CI: 1.02, 1.06], P < .001), and there was no significant change in albumin dosing over time (P = .107).…”

Section: Albumin Practice Patternsmentioning

confidence: 99%

Practice patterns and outcomes associated with intravenous albumin in patients with cirrhosis and acute kidney injury

Patidar

Adibuzzaman

Naved

et al. 2021

Liver International

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Background & Aims: Guidelines recommend albumin as the plasma-expander of choice for acute kidney injury (AKI) in cirrhosis. However, the impact of these recommendations on patient outcomes remains unclear. We aimed to determine the practice-patterns and outcomes associated with albumin use in a large, nationwide-US cohort of hospitalized cirrhotics with AKI.Methods: A retrospective cohort study was performed in hospitalized cirrhotics with AKI using Cerner-Health-Facts database from January 2009 to March 2018. 6786 were included for analysis on albumin-practice-patterns, and 4126 had available outcomes data. Propensity-score-adjusted model was used to determine the association between albumin use, AKI-recovery and in-hospital survival.Results: Median age was 61-years (60% male, 70% white), median serum-creatinine was 1.8 mg/dL and median Model for End-stage Liver Disease Sodium (MELD-Na) score was 24. Albumin was given to 35% of patients, of which 50% received albumin within 48-hours of AKI-onset, and 17% received appropriate weight-based dosing.Albumin was used more frequently in patients with advanced complications of cirrhosis, higher MELD-Na scores and patients admitted to urban-teaching hospitals. After propensity-matching and multivariable adjustment, albumin use was not associated with AKI-recovery (odds ratio [OR] 0.70, 95% confidence-interval [CI]: 0.59-1.07, P = .130) or in-hospital survival (OR 0.76 [95% CI: 0.46-1.25], P = .280), compared with crystalloids. Findings were unchanged in subgroup analyses of patients with varying cirrhosis complications and disease severity. Conclusions: USA hospitalized patients with cirrhosis and AKI frequently do not receive intravenous albumin, and albumin use was not associated with improved clinical outcomes. Prospective randomised trials are direly needed to evaluate the impact of albumin in cirrhotics with AKI.

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Associations Between Mean Arterial Pressure and Poor ICU Outcomes in Critically Ill Patients With Cirrhosis: Is 65 The Sweet Spot?

Cited by 21 publications

References 29 publications

Comparison of Vasopressor Duration in Septic Shock Patients With and Without Cirrhosis

Comparison of Vasopressor Duration in Septic Shock Patients With and Without Cirrhosis

Severe Alcohol‐Associated Hepatitis Is Associated With Worse Survival in Critically Ill Patients With Acute on Chronic Liver Failure

Practice patterns and outcomes associated with intravenous albumin in patients with cirrhosis and acute kidney injury

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