Acute and Critical Care

Original Article

Liver
Early mechanical ventilation for grade IV hepatic encephalopathy is associated with increased mortality among patients with cirrhosis: an exploratory study: Saad Saffo, Guadalupe Garcia-Tsao; Acute Crit Care. 2022;37(3):355-362. Published online August 18, 2022; DOI: https://doi.org/10.4266/acc.2022.00528

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Background
Unresponsive patients with toxic-metabolic encephalopathies often undergo endotracheal intubation for the primary purpose of preventing aspiration events. However, among patients with pre-existing systemic comorbidities, mechanical ventilation itself may be associated with numerous risks such as hypotension, aspiration, delirium, and infection. Our primary aim was to determine whether early mechanical ventilation for airway protection was associated with increased mortality in patients with cirrhosis and grade IV hepatic encephalopathy.
Methods
The National Inpatient Sample was queried for hospital stays due to grade IV hepatic encephalopathy among patients with cirrhosis between 2016 and 2019. After applying our exclusion criteria, including cardiopulmonary failure, data from 1,975 inpatient stays were analyzed. Patients who received mechanical ventilation within 2 days of admission were compared to those who did not. Univariable and multivariable logistic regression analyses were performed to identify clinical factors associated with in-hospital mortality.
Results
Of 162 patients who received endotracheal intubation during the first 2 hospital days, 64 (40%) died during their hospitalization, in comparison to 336 (19%) of 1,813 patients in the comparator group. In multivariable logistic regression analysis, mechanical ventilation was the strongest predictor of in-hospital mortality in our primary analysis (adjusted odds ratio, 3.00; 95% confidence interval, 2.14–4.20; P<0.001) and in all sensitivity analyses.
Conclusions
Mechanical ventilation for the sole purpose of airway protection among patients with cirrhosis and grade IV hepatic encephalopathy may be associated with increased in-hospital mortality. Future studies are necessary to confirm and further characterize our findings.

Citations

Citations to this article as recorded by

Development and validation of a nomogram for predicting in-hospital mortality of intensive care unit patients with liver cirrhosis
Xiao-Wei Tang, Wen-Sen Ren, Shu Huang, Kang Zou, Huan Xu, Xiao-Min Shi, Wei Zhang, Lei Shi, Mu-Han Lü
World Journal of Hepatology.2024; 16(4): 625. CrossRef
Review article: Evaluation and care of the critically ill patient with cirrhosis
Iva Kosuta, Madhumita Premkumar, K. Rajender Reddy
Alimentary Pharmacology & Therapeutics.2024; 59(12): 1489. CrossRef
Using machine learning methods to predict 28-day mortality in patients with hepatic encephalopathy
Zhe Zhang, Jian Wang, Wei Han, Li Zhao
BMC Gastroenterology.2023;[Epub] CrossRef
Experience in Non-invasive Ventilation in Grade 3 Hepatic Encephalopathy
İlhan Ocak, Mustafa Çolak, Erdem Kınacı
Istanbul Medical Journal.2023; 24(3): 295. CrossRef

Case Report

Gastroenterology
Circumferential esophageal perforation resulting in tension hydropneumothorax in a patient with septic shock: Saad Saffo, James Farrell, Anil Nagar; Acute Crit Care. 2021;36(3):264-268. Published online March 11, 2021; DOI: https://doi.org/10.4266/acc.2020.01067

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Abstract PDF

Esophageal perforations occur traumatically or spontaneously and are typically associated with high mortality rates. Early recognition and prompt management are essential. We present the case of a 76-year-old man who was admitted to the medical intensive care unit with fulminant Clostridium difficile colitis, shock, and multi-organ failure. After an initial period of improvement, his condition rapidly deteriorated despite aggressive medical management, and he required mechanical ventilation. Radiography after endotracheal intubation showed interval development of pneumomediastinum and bilateral hydropneumothorax with tension physiology. Chest tube placement resulted in the drainage of multiple liters of dark fluid, and pleural fluid analysis was notable for polymicrobial empyemas. Despite the unusual presentation, esophageal perforation was suspected. Endoscopy ultimately confirmed circumferential separation of the distal esophagus from the stomach, and bedside endoscopic stenting was performed with transient improvement. Two weeks after admission, he developed mediastinitis complicated by recurrent respiratory failure and passed away. This report further characterizes our patient’s unique presentation and briefly highlights the clinical manifestations, management options, and outcomes of esophageal perforations.

Citations

Citations to this article as recorded by

Current approach for Boerhaaves syndrome: A systematic review of case reports
Ippei Yamana, Takahisa Fujikawa, Yuichiro Kawamura, Suguru Hasegawa
World Journal of Meta-Analysis.2023; 11(4): 112. CrossRef

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