Arnaud Galbois1, Philippe Aegerter, Patricia Martel-Samb, Chantal Housset, Dominique Thabut, Georges Offenstadt, Hafid Ait-Oufella, Eric Maury, Bertrand Guidet. 1. 1AP-HP, Hôpital Saint-Antoine, Service de Réanimation Médicale, Paris, France. 2Université Pierre et Marie Curie (UPMC), Univ Paris 06, Sorbonne Universités, Paris, France. 3INSERM, UMR_S 938, CdR Saint-Antoine, Paris, France. 4AP-HP, Hôpital Ambroise Paré, Unité de Recherche Paris-Ouest, Département de Santé Publique, Boulogne, France. 5Université Versailles-Saint Quentin, UPRES EA 2506, Paris, France. 6AP-HP, Hôpital Saint-Antoine, Service d'Hépatologie, Paris, France. 7AP-HP, Hôpital de la Pitié-Salpêtrière, Service d'Hépato-Gastroentérologie, Paris, France. 8INSERM, UMR_S 707, Paris, France.
Abstract
OBJECTIVE: To determine the evolution of the outcome of patients with cirrhosis and septic shock. DESIGN: A 13-year (1998-2010) multicenter retrospective cohort study of prospectively collected data. SETTING: The Collège des Utilisateurs des Bases des données en Réanimation (CUB-Réa) database recording data related to admissions in 32 ICUs in Paris area. PATIENTS: Thirty-one thousand two hundred fifty-one patients with septic shock were analyzed; 2,383 (7.6%) had cirrhosis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Compared with noncirrhotic patients, patients with cirrhosis had higher Simplified Acute Physiology Score II (63.1 ± 22.7 vs 58.5 ± 22.8, p < 0.0001) and higher prevalence of renal (71.5% vs 54.8%, p < 0.0001) and neurological (26.1% vs 19.5%, p < 0.0001) dysfunctions. Over the study period, in-ICU and in-hospital mortality was higher in patients with cirrhosis (70.1% and 74.5%) compared with noncirrhotic patients (48.3% and 51.7%, p < 0.0001 for both comparisons). Cirrhosis was independently associated with an increased risk of death in ICU (adjusted odds ratio = 2.524 [2.279-2.795]). In patients with cirrhosis, factors independently associated with in-ICU mortality were as follows: admission for a medical reason, Simplified Acute Physiology Score II, mechanical ventilation, renal replacement therapy, spontaneous bacterial peritonitis, positive blood culture, and infection by fungus, whereas direct admission and admission during the most recent midterm period (2004-2010) were associated with a decreased risk of death. From 1998 to 2010, prevalence of septic shock in patients with cirrhosis increased from 8.64 to 15.67 per 1,000 admissions to ICU (p < 0.0001) and their in-ICU mortality decreased from 73.8% to 65.5% (p = 0.01) despite increasing Simplified Acute Physiology Score II. In-ICU mortality decreased from 84.7% to 68.5% for those patients placed under mechanical ventilation (p = 0.004) and from 91.2% to 78.4% for those who received renal replacement therapy (p = 0.04). CONCLUSIONS: The outcome of patients with cirrhosis and septic shock has markedly improved over time, akin to the noncirrhotic population. In 2010, the in-ICU survival rate was 35%, which now fully justifies to admit these patients to ICU.
OBJECTIVE: To determine the evolution of the outcome of patients with cirrhosis and septic shock. DESIGN: A 13-year (1998-2010) multicenter retrospective cohort study of prospectively collected data. SETTING: The Collège des Utilisateurs des Bases des données en Réanimation (CUB-Réa) database recording data related to admissions in 32 ICUs in Paris area. PATIENTS: Thirty-one thousand two hundred fifty-one patients with septic shock were analyzed; 2,383 (7.6%) had cirrhosis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Compared with noncirrhotic patients, patients with cirrhosis had higher Simplified Acute Physiology Score II (63.1 ± 22.7 vs 58.5 ± 22.8, p < 0.0001) and higher prevalence of renal (71.5% vs 54.8%, p < 0.0001) and neurological (26.1% vs 19.5%, p < 0.0001) dysfunctions. Over the study period, in-ICU and in-hospital mortality was higher in patients with cirrhosis (70.1% and 74.5%) compared with noncirrhotic patients (48.3% and 51.7%, p < 0.0001 for both comparisons). Cirrhosis was independently associated with an increased risk of death in ICU (adjusted odds ratio = 2.524 [2.279-2.795]). In patients with cirrhosis, factors independently associated with in-ICU mortality were as follows: admission for a medical reason, Simplified Acute Physiology Score II, mechanical ventilation, renal replacement therapy, spontaneous bacterial peritonitis, positive blood culture, and infection by fungus, whereas direct admission and admission during the most recent midterm period (2004-2010) were associated with a decreased risk of death. From 1998 to 2010, prevalence of septic shock in patients with cirrhosis increased from 8.64 to 15.67 per 1,000 admissions to ICU (p < 0.0001) and their in-ICU mortality decreased from 73.8% to 65.5% (p = 0.01) despite increasing Simplified Acute Physiology Score II. In-ICU mortality decreased from 84.7% to 68.5% for those patients placed under mechanical ventilation (p = 0.004) and from 91.2% to 78.4% for those who received renal replacement therapy (p = 0.04). CONCLUSIONS: The outcome of patients with cirrhosis and septic shock has markedly improved over time, akin to the noncirrhotic population. In 2010, the in-ICU survival rate was 35%, which now fully justifies to admit these patients to ICU.
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