Risk factors and outcome of hepatic dysfunction (HD) in critically ill surgical patients (CrISP)
Introduction: HD is a common component of multiple organ dysfunction syndrome (MODS), but no specific therapy exists. With the clinical emphasis on prevention, we examined factors for adverse outcomes (mortality-M, prolonged ICU stay-ULOS, and severe HD) in 663 CrISP with MODS. Methods: Tertiary-care surgical ICU; no liver transplants performed. Prospective multivariate analysis of 472 patients with total bilirubin > 1.3 mg/dl according to MOD score of Marshall, et. al., (CCM 1995; 23:1638), compared with 191 comparably ill patients with MODS but no HD. Three pre-existing entities (cirrhosis, hepatitis, ETOH), 3 treatments (TPN, pressors, transfusions) and 8 admission entities (e.g., GI bleed, sepsis), were noted. Statistics: Mean x±SEM, univariate/multivariate ANOVA, p<0.05. Results: Patients with/without HD were similar in age (overall, 66±1, p=0.87), APACHE III (67±2, p=0.96), use of TPN (38%, p=0.10) and the eventual magnitude of pulmonary (p=0.10), renal (p=0.17), hematologic (p=0.65) and neurologic (p=0.12) dysfunction. HD caused longer ULOS (15 vs. 7 days, p<0.0001) and higher M (29 vs 21%; p<0.05). Cirrhosis, cholecystitis, and pancreatitis predicted only the magnitude of HD. (See Table) Conclusions: HD causes excess mortality and prolonged ULOS. Hepatitis, GI bleeding, and sepsis pose a particular risk of adverse outcomes. Avoidance of TPN in favor of enteral feeding may be an effective preventive measure, and should be considered in TPN-treated patients who develop hyperbilirubinemia. Multivariate ANOVA-Dependent variable more HD M ULOS ETOH <0.05 <0.01 Hepatitis <0.0001 <0.05 GI Bleeding <0.001 <0.01 Hypotension <0.05 <0.0001 Sepsis <0.0001 <0.0001 <0.0001 TPN <0.0001 <0.0001 <0.0001 Pressors <0.05 <0.0001 <0.0001 Transfusion >6U <0.0001 <0.01 <0.01.