How do cirrhotics die during a critical illness?
Critical illness in a patient with cirrhosis comes in the form of infections and other organ failures and also can arise from complications of the liver disease. Our aim was to reduce this mortality in our patients while they are waiting for a transplant.
If we look at the available data, we know that liver failure and cardiovascular disease constitute the major chunk of patients who die with a diagnosis of cirrhosis.
One must be clear in interpreting this data. I am more interested in preventable causes that directly translates into longer life for individual patients. The key aspect is correcting GI bleeding risks, complete cardiovascular evaluation, stopping alcohol, drugs and smoking, and good infection prevention measures. What cannot be prevented is progressive liver failure, which can be addressed only by liver transplantation.
Death in cirrhotics during an acute illness is a different ball game. Higher mortality in these patients are best assessed by extent of organ damage and the ability to control the complication. I would illustrate with examples.
The risk of death in patients with cirrhosis is identified using different variables. In stable cirrhotics, the one or two year risk of death can be known from calculating the Child Pugh Score. The three month mortality is assessed using the MELD score. For those patients, with acute worsening of liver failure, the CLIF score provides a means of assessing the risk of death.
Among the most common causes of death in our patients, alcohol abuse within the last month ranks high. We have also seen sepsis contributing to mortality in these patients. But what are the elements that we use to predict death in our patients?
ICU admission for severe sepsis irrespective of the site of infection (Low BP, requiring medications to support BP in the presence of infection in the blood) and/or massive blood vomiting that leads to drop in blood pressure along with the necessity of using a ventilator predicts a very high chance of death in cirrhotics (approximately 90%)
Mechanical ventilation more than a week along with high bilirubin levels also predicts death.
The problem is that cirrhotics have no reserve to support organs - kidneys are fickle, blood vessels are already dilated and they have immune response to infection and are also highly susceptible to infection. Even a small insult leads to worsening of status and death looms as a possibility.
What I always tell my patients is that they should never get into a situation that leads to death. When MELD scores are > 20, it is good that they follow up regularly with the hepatologist and follow standard preventive measures as outlined in the 3rd paragraph.
If we look at the available data, we know that liver failure and cardiovascular disease constitute the major chunk of patients who die with a diagnosis of cirrhosis.
One must be clear in interpreting this data. I am more interested in preventable causes that directly translates into longer life for individual patients. The key aspect is correcting GI bleeding risks, complete cardiovascular evaluation, stopping alcohol, drugs and smoking, and good infection prevention measures. What cannot be prevented is progressive liver failure, which can be addressed only by liver transplantation.
Death in cirrhotics during an acute illness is a different ball game. Higher mortality in these patients are best assessed by extent of organ damage and the ability to control the complication. I would illustrate with examples.
The risk of death in patients with cirrhosis is identified using different variables. In stable cirrhotics, the one or two year risk of death can be known from calculating the Child Pugh Score. The three month mortality is assessed using the MELD score. For those patients, with acute worsening of liver failure, the CLIF score provides a means of assessing the risk of death.
Among the most common causes of death in our patients, alcohol abuse within the last month ranks high. We have also seen sepsis contributing to mortality in these patients. But what are the elements that we use to predict death in our patients?
ICU admission for severe sepsis irrespective of the site of infection (Low BP, requiring medications to support BP in the presence of infection in the blood) and/or massive blood vomiting that leads to drop in blood pressure along with the necessity of using a ventilator predicts a very high chance of death in cirrhotics (approximately 90%)
Mechanical ventilation more than a week along with high bilirubin levels also predicts death.
The problem is that cirrhotics have no reserve to support organs - kidneys are fickle, blood vessels are already dilated and they have immune response to infection and are also highly susceptible to infection. Even a small insult leads to worsening of status and death looms as a possibility.
What I always tell my patients is that they should never get into a situation that leads to death. When MELD scores are > 20, it is good that they follow up regularly with the hepatologist and follow standard preventive measures as outlined in the 3rd paragraph.
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