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.
Crit Care Med. 2014 Jul;42(7):1666-75. doi: 10.1097/CCM.0000000000000321.
To determine the evolution of the outcome of patients with cirrhosis and septic shock.
A 13-year (1998-2010) multicenter retrospective cohort study of prospectively collected data.
The Collège des Utilisateurs des Bases des données en Réanimation (CUB-Réa) database recording data related to admissions in 32 ICUs in Paris area.
Thirty-one thousand two hundred fifty-one patients with septic shock were analyzed; 2,383 (7.6%) had cirrhosis.
None.
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).
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.
确定肝硬化合并感染性休克患者结局的演变情况。
一项前瞻性收集数据的 13 年（1998-2010 年）多中心回顾性队列研究。
记录巴黎地区 32 个 ICU 住院患者数据的 Collège des Utilisateurs des Bases des données en Réanimation（CUB-Réa）数据库。
分析了 31251 例感染性休克患者；其中 2383 例（7.6%）合并肝硬化。
无。
与非肝硬化患者相比，肝硬化患者的简化急性生理学评分 II 更高（63.1±22.7 比 58.5±22.8，p<0.0001），且肾功能（71.5%比 54.8%，p<0.0001）和神经系统（26.1%比 19.5%，p<0.0001）障碍的发生率更高。研究期间，肝硬化患者 ICU 内和住院死亡率（分别为 70.1%和 74.5%）高于非肝硬化患者（分别为 48.3%和 51.7%，p<0.0001）。肝硬化与 ICU 死亡风险增加独立相关（校正比值比=2.524[2.279-2.795]）。在肝硬化患者中，与 ICU 内死亡相关的独立因素如下：因内科原因入院、简化急性生理学评分 II、机械通气、肾脏替代治疗、自发性细菌性腹膜炎、血培养阳性和真菌感染，而直接入院和最近中期（2004-2010 年）入院与死亡风险降低相关。1998 年至 2010 年，肝硬化患者感染性休克的患病率从每 1000 例 ICU 入院 8.64 例增加至 15.67 例（p<0.0001），其 ICU 死亡率从 73.8%降至 65.5%（p=0.01），尽管简化急性生理学评分 II 有所增加。接受机械通气的患者 ICU 内死亡率从 84.7%降至 68.5%（p=0.004），接受肾脏替代治疗的患者 ICU 内死亡率从 91.2%降至 78.4%（p=0.04）。
肝硬化合并感染性休克患者的结局在过去 10 年中得到显著改善，与非肝硬化患者相似。2010 年，ICU 内生存率为 35%，现在完全有理由将这些患者收入 ICU。
