Colpaert, Kirsten

Decruyenaere, Alexander

Decruyenaere, Johan

Van Coile, Laura

Van den broecke, Astrid

Van Vlierberghe, Hans

Ghent University Academic Bibliography

Fig. 328 (Abstract 1028) Logistic regressionIntensive Care Medicine Experimental 2017, 5(Suppl 2):44 Page 515 of 5421027Characteristics of immunocompromised patients with influenza Avirus admitted to the intensive care unitC. León Moya1, A. Gutiérrez Pizarraya1, M.L. Cantón Bulnes1, Á. ArenzanaSeisdedos1, A. Rodríguez2, J. Garnacho-Montero11Hospital Universitario Virgen Macarena, Sevilla, Spain; 2HospitalUniversitari Joan XXIII, Tarragona, SpainCorrespondence: C. León MoyaIntensive Care Medicine Experimental 2017, 5(Suppl 2):1027INTRODUCTION. Information about immunocompromised patientsinfected with influenza A virus requiring admission to the ICU islacking. The objective of this study was to know the clinicalcharacteristics of these patients and to identify variables associatedwith mortality.METHODS. A prospective multicenter observational cohort study wasbased on data from the GETGAG/SEMICYUC registry (2009–2015)collected by 148 Spanish ICUs. All patients admitted to the ICU withthe diagnosis of influenza A virus infection were included.Immunosuppression was defined as any primary immunodeficiencyor immunodeficiency secondary to human immunodeficiency virus(HIV) infection, active malignancy, immunodeficiency secondary toradiation treatment or use of cytotoxic drugs or corticosteroids (dailydose >40 mg of prednisolone or the equivalent for >2 weeks),immunological disease, solid organ transplant, and haematologicaldisease. Factors associated with mortality in immunocompromisedpatients were assessed by logistic regression analysis.RESULTS. Of 2315 patients with influenza A infection, 289 (12.5%)were classified as immunocompromised. Mortality was significantlyhigher in immunocompromised patients (47.1% vs 20.1%; p < 0.001).Severity of illness and the rates of health-care infection, early use ofoseltamivir and administration of corticosteroids were significantlygreater in immunocompromised subjects. In this group of patients,factor independently associated with mortality were: APACHE II score(OR =1.09, 95% CI = 1.04-1.13, p < 0.001), stage 3 of acute renal in-sufficiency (OR = 2.33, 95% CI = 1.69-4.63, p < 0.05), use of vasopres-sor drugs (OR = 4.69, 95% CI = 2.44-9.03, p < 0.001) and the use ofcorticosteroid (OR = 1.89, 95% CI = 1.06-3.37, p < 0.05).CONCLUSION. Immunocompromised individuals with influenza Aadmitted to the ICU have a poorer outcome than patients withoutimmunocompromise. In this population, we should avoid the use ofcorticosteroids because it is independently associated with a highermortality.Liver failure: Nutrition and metabolism1028Development of a multivariate prediction model for mortality in acohort of 1177 critically ill patients with hypoxic hepatitisA. Van den broecke1, L. Van Coile1, A. Decruyenaere2, H. VanVlierberghe3, K. Colpaert4, J. Decruyenaere41Ghent University, Faculty of Medicine and Health Sciences, Ghent,Belgium; 2Ghent University Hospital, Department of Internal Medicine,Ghent, Belgium; 3Ghent University Hospital, Department of Hepatologyand Gastroenterology, Ghent, Belgium; 4Ghent University Hospital,Department of Intensive Care Medicine, Ghent, BelgiumCorrespondence: A. Van den broeckeIntensive Care Medicine Experimental 2017, 5(Suppl 2):1028INTRODUCTION. Hypoxic hepatitis (HH) (“ischemic hepatitis” or“shock liver”) is a common cause of hepatic dysfunction in an ICU, ishistologically characterized by centrilobular liver cell necrosis and iscaused by an insufficient oxygen delivery to hepatocytes. Typical forHH is the sudden, significant rise (>5x ULN) of aspartateaminotransferase (AST) in response to hemodynamic failure.OBJECTIVES. The aim of this study was to identify mortality riskfactors of HH using a multivariate prediction model and to assess thepredictive accuracy of 2 existing models (Fuhrmann et al. [2] andRaurich et al. [3]).METHODS. The study cohort consisted of 1177 adults with a firstepisode of HH (AST >5x ULN) out of 29874 patients admitted to theICU of the Ghent University Hospital (UZG) between January 1st,2007 and September 21st, 2015. The incidence of HH was 4.2% andthe hospital mortality 42.8%. Further detailed study results aredescribed in another report [1]. 29 parameters were retrospectivelycollected as potential risk factors based on clinical importance. Theassociation with mortality was studied using logistic regression at thetime of maximal AST value. Predictive accuracy of the models wasassessed by the area under the receiver operating characteristiccurve (AUC), the calibration curve and the Hosmer-Lemeshow (HL)test. As the 2 existing models were developed in patients with AST>20x ULN, only this subgroup (n = 460) was used for their validation.RESULTS. Resp. 8 and 2 risk factors are excluded based on missingvalues and correlation. The remaining 19 variables have 1153complete cases. After a backward elimination procedure, themultivariate UZG model indicates that age (OR 1.03 per year), cardiacfailure (OR 8.55), septic shock (OR 12.25), hypovolemic shock (OR7.99), lung embolism (OR 14.04), acute respiratory failure (OR 2.38),acute-on-chronic respiratory failure (OR 6.68) and mechanical ventila-tion (OR 2.24) are most significantly (all P < 0.001) associated withmortality. Additionally, INR (OR 1.27 per unit, P = 0.002), hyperther-mia (OR 14.58, P = 0.019) and AST (OR 1.01 per 100U/L, P = 0.05) aresignificantly associated. pH (OR 0.56 per 0.1) and trombocytes (OR0.98 per 104/ml) are inversely associated (both P < 0.001). The UZGmodel has a good discrimination (AUC 0.79) and shows a good fitbetween the observed and expected mortality (HL: P = 0.67). On thecontrary, the models of Raurich et al. and Fuhrmann et al. have aweak discriminative capacity (AUC 0.59 and 0.67, resp.).CONCLUSIONS. This is by far the largest single-centre cohort studyof HH described in literature. 7 mortality risk factors associated withHH are identified. Unlike the 2 existing models, the UZG model has agood discrimination and calibration.REFERENCES[1] Van Coile L, Van den broecke A et al. [abstract submitted to the30th Annual Congress of ESICM].[2] Fuhrmann V et al. Intensive Care Med. 2009;35(8):1397–405.[3] Raurich JM et al. J Anesth. 2011;25(1):50–6.1029Epidemiology, cause, evolution and outcome in a cohort of 1177critically ill patients with hypoxic hepatitisL. Van Coile1, A. Van den broecke1, A. Decruyenaere2, H. VanVlierberghe3, K. Colpaert4, J. Decruyenaere41Ghent University, Faculty of Medicine and Health Sciences, Ghent,Belgium; 2Ghent University Hospital, Department of Internal Medicine,Ghent, Belgium; 3Ghent University Hospital, Department of Hepatologyand Gastroenterology, Ghent, Belgium; 4Ghent University Hospital,Department of Intensive Care Medicine, Ghent, BelgiumCorrespondence: L. Van CoileIntensive Care Medicine Experimental 2017, 5(Suppl 2):1029INTRODUCTION. Hypoxic hepatitis (HH) (“ischemic hepatitis” or“shock liver”) is histologically characterized by centrilobular liver cellnecrosis and is caused by an insufficient oxygen delivery toFig. 329 (Abstract 1030) ROC curves of MCF for Child-Pugh groupsIntensive Care Medicine Experimental 2017, 5(Suppl 2):44 Page 516 of 542hepatocytes. Typical for this type of liver cell necrosis is the sudden,significant rise (>5x ULN) of aspartate aminotransferase (AST) inresponse to cardiac, circulatory or respiratory failure. Other causes ofAST rise should be excluded before diagnosing HH. Treatment of HHrelies on the prompt correction of the underlying dysfunction.OBJECTIVES. The aim of this study is to describe the epidemiology,cause, evolution and outcome of critically ill patients with HH. Moreinsight may raise more awareness and could result in a fasterdiagnosis, which may contribute to a better prognosis.METHODS. The screened population consists of all adults (n = 29874)admitted to the ICU at the Ghent University Hospital between January1st, 2007 and September 21st, 2015. 4012 patients had at least oneepisode of AST-levels above 5x ULN. After exclusion of 2835 patientswith another cause of elevated AST-levels (e.g. liver surgery, toxic hepa-titis, cholangitis,…), a cohort of 1177 first episodes of patients with HHwere identified. These patients are classified by underlying cause of HH.The most important outcome variable is ICU and hospital mortality.RESULTS. The incidence of HH is 4.2%. The male/female ratio is 1.5and the median age is 66 years. The causes of HH are cardiac failure(40.2%), septic shock (28.3%), post-anesthesia without overt evidenceof an acute cardiac or respiratory event (11.6%), hypovolemic shock(8.9%), acute respiratory failure (6.0%), acute-on-chronic respiratoryfailure (3.1%), pulmonary embolism (1.4%) and hyperthermia (0.5%).The hospital mortality associated with HH is 42.8%, of which 90.4%occurred during ICU stay. Pulmonary embolism and septic shockhave the highest (56.2% and 52.9%, resp.) and fastest (median sur-vival 5.4 and 12.3 days, resp.) mortality. Contrary to previous studies,patients with a limited rise of AST (5xULN < AST < 10xULN) were alsoincluded. This subgroup contains 439 patients and has a mortality of26.2%. Another subgroup of 136 patients appeared to develop HHafter major surgery with general anesthesia despite having no prob-lem during surgery. This subgroup, with still a considerable mortalityof 7.4%, was not described in previous studies.CONCLUSIONS. This is by far the largest single-centre cohort studyof HH described in literature. With an incidence of 4.2%, HH is a fre-quent cause of hepatic dysfunction in critically ill patients and is as-sociated with a high hospital mortality of 42.8%. The principal causesare acute cardiac disease and septic shock, which include more than2/3 of all episodes. Clinicians should search actively for an un-detected underlying hemodynamic or respiratory problem even inpatients with moderately elevated AST values or with AST elevationsafter major uncomplicated surgery.1030Thromboelastometry - relation to the severity of liver cirrhosis inpatients considered for liver transplantationG. Dumitrescu1, A. Januszkiewicz1, A. Ågren2, M. Magnusson3, S. Wahlin4,J. Wernerman11Karolinska Institutet, Anestesia and Intensive Care, Stockholm, Sweden;2Karolinska Institutet, Department of Medicine, Division of Hematology,Coagulation Unit, Stockholm, Sweden; 3Karolinska Institutet, CLINTEC,MMK, Clinical Chemistry and Blood Coagulation Research, Stockholm,Sweden; 4Karolinska Institutet, Division of Hepatology, Centre forDigestive Diseases, Stockholm, SwedenCorrespondence: G. DumitrescuIntensive Care Medicine Experimental 2017, 5(Suppl 2):1030INTRODUCTION. The severity of liver disease is assessed by scoringsystems which include the conventional coagulation test PT-INR.However PT-INR is not predictive of bleeding in liver disease andthromboelastometry has been suggested to give a better overviewof the coagulation system in these patients. It has now been sug-gested that coagulation as reflected by tromboelastomety, particu-larly maximum clot firmness (MCF), may also be used for prognosticpurposes in patients with stable chronic liver disease.OBJECTIVES. The objective of our study was to investigate ifthrombelastometry may discriminate the degree of liver insufficiencyaccording to the scoring systems Child Pugh and Model for End-stage Liver Disease (MELD).METHODS. Forty adult patients with stable chronic liver disease ofdifferent etiologies and stages were included in this observationalcross-sectional study. The severity of liver disease was evaluatedusing the Child-Pugh score and the MELD score, and blood samplesfor biochemistry, conventional coagulation tests and thromboelasto-metry were collected at the time of the final assessment for livertransplantation. Statistical comparisons for the studied parameterswith scores of severity were made using Spearman´s correlation testand receiver operating characteristic (ROC) curves.Child-Pugh score A + B Child-Pugh score CNo. 22 18Child-Pugh score 8(6–9) 11(10–13)MELD ≤16 MELD >17No. 21 19MELD score 13(7–16) 20(17–27)[Number of patients (No). Scores as median (range).]RESULTS. Spearman's correlation coefficients indicated that thethromboelastometric parameters did not correlate with Child-Pughor MELD scores. The ROC curves of the thromboelastometric parame-ters could not differentiate advanced stages from early stages of livercirrhosis.CONCLUSIONS. standard thromboelastometry cannot discriminatethe stage of chronic liver disease in patients with severe chronic liverdisease.REFERENCE(S)1. Tripodi A, Primignani M, Chantarangkul V, et al. The coagulopathyof cirrhosis assessed by thromboelastometry and its correlation withconventional coagulation parameters. Thrombosis research.2009;124(1):132–136.2. Wiesner R, Edwards E, Freeman R, et al. Model for end-stage liverdisease (MELD) and allocation of donor livers. Gastroenterology.2003;124(1):91–96.3. Lentschener C, Flaujac C, Ibrahim F, et al. Assessment ofhaemostasis in patients with cirrhosis: Relevance of the ROTEMtests?: A prospective, cross-sectional study. Eur J Anaesthesiol.2016;33(2):126–133.GRANT ACKNOWLEDGMENTThe study was supported by grants to Jan Wernerman from theSwedish Medical Research Council (project 04210) and the CountyCouncil of Stockholm (project 502033).

Epidemiology, cause, evolution and outcome in a cohort of 1177 critically ill patients with hypoxic hepatitis

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Epidemiology, cause, evolution and outcome in a cohort of 1177 critically ill patients with hypoxic hepatitis

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