Alcoholic liver disease in intensive care Journal club, april 2017 Tom Beach Alcoholic liver disease in intensive care

The paper Study objective Journal club, April 2017 The paper Alcoholic liver disease on the intensive care unit - Outcomes and prognostication Beck J et al. JICS.2017;18(1):24-29 Study objective To determine the outcome and prognostic factors for patients with alcoholic liver disease requiring admission to the intensive care unit

Primary outcome Secondary outcomes Journal club, April 2017 Primary outcome All cause hospital mortality in patients with alcoholic liver disease admitted to the ICU Secondary outcomes Assessment of disease severity scores to try to identify predictive factors for survival from ICU & hospital discharge to guide clinical decision making

methodology Retrospective observational cohort study Journal club, April 2017 methodology Retrospective observational cohort study All patients admitted to an ICU bed across the Leeds Teaching Hospitals NHS Trust 5 year period between January 2006 & December 2010 Study size was set at either 100 patients or the 5 year study period, whichever came sooner.

Journal club, april 2017 methodology ALD defined as chronic alcohol excess & proven liver damage in the absence of another cause Patients with ALD were identified through a number of sources: Admission book Gastroenterology consultant ICU database The diagnosis was reviewed in all cases & patients excluded if they did not meet the criteria for diagnosis Also excluded if under the care of the specialist transplant or HPB services

methodology Sequential Organ Failure Assessment score (SOFA) Journal club, april 2017 methodology Sequential Organ Failure Assessment score (SOFA) Model for End-stage Liver Disease (MELD) Previously been identified as potential prognostic markers for patients with ALD

Patient population 82 patients included Journal club, april 2017 Patient population 82 patients included 174 patients initially identified. 78 excluded. 14 notes unavailable Most. Patients were Child's Pugh C on admission The most common admission diagnosis was variceal bleeding

Journal club, April 2017 Statistical Tests Descriptive statistics were allied to patient demographics Categorical variables: Whole number & percentage Differences evaluated using Chi-squared test Continuous variables: Mean & median Differences evaluated using Mann-Whitney U test Correlation with mortality was analysed with Mann-Whitney U test & Pearson's correlation coefficient

Results ICU mortality 46% In-hospital mortality 67% Journal club, april 2017 Results ICU mortality 46% In-hospital mortality 67% Higher for first presentation compared with established ALD: 83% vs 63% (did not reach statistical significance)

Results Mortality varied by diagnosis Isolates variceal bleed had the Journal club, April 2017 Results Mortality varied by diagnosis Isolates variceal bleed had the best: 52% Sepsis & HRS had the worst: >85% Also varied by intervention on ICU: I+V 78%, inotropic support 83%, RRT 80%

Results SOFA score had the closest correlation with mortality Journal club, april 2017 Results SOFA score had the closest correlation with mortality SOFA score on ICU admission >10 was associated with 97% in-hospital mortality SOFA score did not increase at 48hrs in survivors Any deterioration: 88% in-hospital mortality Those who's scores increased but survived >48hrs had a 79% in-hospital mortality

Learning points Presenting diagnosis matters Journal club, april 2017 Learning points Presenting diagnosis matters Increased morality for first presentation of ALD SOFA score correlated most closely with outcome SOFA score >10 associated with 97% mortality Deterioration from admission carries a poor prognosis Re-assessment & MDT discussion at 48hrs advised

Limitations Retrospective study Relatively small numbers Journal club, April 2017 Limitations Retrospective study Relatively small numbers Unable to locate records for 14 patients No control group Delay from data collection to publication

Will this paper change clinical practice? Journal club, April 2017 Will this paper change clinical practice? Probably... Authors state that data are not strong enough to provide clear guidance on who should be admitted or declined ICU care Should aid clinical decision making

Questions?