INCIDENCIA Y PRONÓSTICO DE LA DISFUNCIÓN HEPÁTICA EN

ENFERMOS CRÍTICOS

Antonio ArtigasCentro de CríticosCIBER Enfermedades RespiratoriasHospital de SabadellUniversidad Autónoma de BarcelonaSpain

Organ Dysfunction in Severe Sepsis Involves Tissue Dysoxia

Infection

... . ... .

.... ....

Systemic response: Genetic make-upPhysiologic reserve

Diffuse Endothelial Activation

Microvascular DysfunctionRegional mis-matchof O2 supply/demand

Mitochondrial dysfunction

Hypoxic Hypoxia

Cytopathic Hypoxia

Fink. Crit Care Med 2002;6:491 Brealey. Lancet 2002:360:219 Ince. Crit Care Med 1999;27:1369

Identifying Acute Organ Dysfunction as a Marker of Severe

SepsisTachycardiaHypotension

↑ CVP↑ PAOP

Jaundice↑ Enzymes↓ Albumin

↑ PT

Altered Consciousness

ConfusionPsychosis

TachypneaPaO2 <70 mm Hg

SaO2 <90%PaO2/FiO2 ≤300

OliguriaAnuria

↑ Creatinine

↓ Platelets↑ PT/APTT↓ Protein C↑ D-dimer

MULTIPLE ORGAN DYSFUNCTION SCORE AND MORTALITY

ORGAN DYSFUNCTION SCORES

INTRODUCTION

• Hepatic Dysfunction indicates poor outcome in critically ill patients.

• Exact incidence and prognostic relevance?

• Is regarded as a late organ failure associated with a poor outcome.

EARLY HEPATIC DYSFUNCTION:

DIAGNOSIS

• No physiologic variable for early detection HD.

• Diagnostic criteria are based on laboratory test: Bilirubin, PT

• Variability: ascitis, transaminases, alkaline phosphatase

• Serum bilirubin is a stable and powerful marker of HD.

EARLY HEPATIC DYSFUNCTION:

SERUM BILIRUBIN

• Impairment metabolism, conjugation, and bile secretion.

• Key component of prognostic scores for liver diseases and criticalyy ill patients.

Crit Care Med 1998;26;1793-1800

EARLY HEPATIC DYSFUNCTION: CLINICAL CHARACTERISTICS

Crit Care Med 2007;35:1099-1104Incidence: 10.9%

IMPACT OF EARLY HEPATIC DYSFUNCTION ON MORTALITY

Crit Care Med 2007;35:1099-1104R R mortality 1.65 (95% CI, 1.46-1.86)

HOSPITAL MORTALITY AND BILIRUBIN LEVELS

Crit Care Med 2007;35:1099-1104

Max. BILIRUBIN LEVEL (<48 hrs) and ADJUSTED RISK HOSPITAL MORTALITY

Crit Care Med 2007;35:1099-1104

EARLY HEPATIC DYSFUNCTION:

CASE CONTROL STUDY

Crit Care Med 2007;35:1099-1104

Sequential Changes in SOFA Score Correlates with 28-day Mortality

Levy MM, et al. Crit Care med 2005;33:2194-2201

Subgroups – Disease Severity MeasuresPrimaryHematologic Organ Failure

YesNo

Hematologic SOFA0 or 12 to 4

Renal Organ FailureYesNo

Renal SOFA0 or 12 to 4

Metabolic Organ FailureYesNo

Hepatic SOFA0 or 12 to 4

Organ Failures12345

1690

2681422

1317368

710980

1122564

5811109

1265275

41854343223561

24.7

27.524.2

23.927.7

32.519.1

20.432.6

29.822.0

22.731.4

19.520.726.238.732.3

30.8

36.929.7

28.340.0

40.523.8

25.741.4

41.525.4

30.236.2

21.226.034.446.653.3

N Trt Plc

0.5 0.6 0.7 0.8 1 1.25 1.67 20.9Relative Risk of Death (Point Estimate and 95% CI)6765.01

CONCLUSIONS

• Early Hepatic Dysfunction is frequent and associated with higher mortality.

• Bilirubin is a good biomarker and prognostic factor.

• Sequential changes correlates with treatment response and mortality.