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

2. 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

3. 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

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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)

10. 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%

11. 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

12. 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

13. 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

14. 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

15. Questions?