Boone M Dustin, Celi Leo A, Ho Ben G, Pencina Michael, Curry Michael P, Lior Yotam, Talmor Daniel, Novack Victor
Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
Department of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard-Massachusetts Institute of Technology Division of Health Science Technology, Cambridge, MA.
J Crit Care. 2014 Oct;29(5):881.e7-13. doi: 10.1016/j.jcrc.2014.05.013. Epub 2014 May 28.
Cirrhosis is a common condition that complicates the management of patients who require critical care. There is interest in identifying scoring systems that may be used to predict outcome because of the poor odds for recovery despite high-intensity care. We sought to evaluate how Model for End-Stage Liver Disease (MELD), an organ-specific scoring system, compares with other severity of illness scoring systems in predicting short- and long-term mortality for critically ill cirrhotic patients.
This was a retrospective cohort study involving seven intensive care units (ICUs) in a tertiary care, academic medical center. Adult patients with cirrhosis who were admitted to an ICU between 2001 and 2008 were evaluated. Severity of illness scores (MELD and Sequential Organ Failure Assessment [SOFA]) were calculated on admission and at 24 and 48 hours. The primary end points were 28-day and 1-year all-cause mortality.
Of 19742 ICU hospitalizations, 848 had cirrhosis. Relevant data were available for 521 patients (73%). Of these cases, 353 patients (69.5%) were admitted to medical ICU (MICU), and the other 155 (30.5%), to surgical unit. Alcohol abuse and hepatitis C were the most common reasons for cirrhosis. Patients who died within 28 days were more likely to receive mechanical ventilation, pressors, and renal replacement therapy. Among 353 medical admissions, both MELD and SOFA were found to be significantly associated with both 28-day and 1-year mortality. Among the 155 surgical admissions, both scores were found to be not significant for 28-day mortality but were significant for 1 year.
Our results demonstrate that the prognostic ability of a variety of scoring systems strongly depends on the patient population. In the MICU population, each model (MELD + SOFA, MELD, and SOFA) demonstrates excellent discrimination for 28-day and 1-year mortality. However, these scoring systems did not predict 28-day mortality in the surgical ICU group but were significant for 1-year mortality. This suggests that patients admitted to a surgical ICU will behave similarly to their MICU cohort if they survive the perioperative period.
肝硬化是一种常见病症，会使需要重症监护的患者的治疗变得复杂。鉴于尽管进行了高强度治疗但康复几率仍很低，人们对确定可用于预测预后的评分系统很感兴趣。我们试图评估终末期肝病模型（MELD）这一器官特异性评分系统与其他疾病严重程度评分系统相比，在预测重症肝硬化患者短期和长期死亡率方面的表现。
这是一项回顾性队列研究，涉及一家三级医疗学术医学中心的七个重症监护病房（ICU）。对2001年至2008年间入住ICU的成年肝硬化患者进行评估。在入院时、24小时和48小时计算疾病严重程度评分（MELD和序贯器官衰竭评估[SOFA]）。主要终点是28天和1年的全因死亡率。
在19742次ICU住院治疗中，848例患有肝硬化。521例患者（73%）有相关数据。在这些病例中，353例患者（69.5%）入住内科ICU（MICU），另外155例（30.5%）入住外科病房。酒精滥用和丙型肝炎是肝硬化最常见的原因。在28天内死亡的患者更有可能接受机械通气、血管活性药物和肾脏替代治疗。在353例内科入院患者中，发现MELD和SOFA均与28天和1年死亡率显著相关。在155例外科入院患者中，两个评分对28天死亡率均无显著意义，但对1年死亡率有显著意义。
我们的结果表明，各种评分系统的预后能力很大程度上取决于患者群体。在内科ICU患者群体中，每个模型（MELD + SOFA、MELD和SOFA）在预测28天和1年死亡率方面都表现出出色的辨别力。然而，这些评分系统在外科ICU组中未能预测28天死亡率，但对1年死亡率有显著意义。这表明入住外科ICU的患者如果能度过围手术期，其表现将与内科ICU的同类患者相似。
