Saffo Saad, Garcia-Tsao Guadalupe
Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA.
Department of Internal Medicine, Section of Digestive Diseases, West Haven Veteran Affairs Medical Center, West Haven, CT, USA.
Acute Crit Care. 2022 Aug;37(3):355-362. doi: 10.4266/acc.2022.00528. Epub 2022 Aug 18.
Unresponsive patients with toxic-metabolic encephalopathies often undergo endotracheal intubation for the primary purpose of preventing aspiration events. However, among patients with pre-existing systemic comorbidities, mechanical ventilation itself may be associated with numerous risks such as hypotension, aspiration, delirium, and infection. Our primary aim was to determine whether early mechanical ventilation for airway protection was associated with increased mortality in patients with cirrhosis and grade IV hepatic encephalopathy.
The National Inpatient Sample was queried for hospital stays due to grade IV hepatic encephalopathy among patients with cirrhosis between 2016 and 2019. After applying our exclusion criteria, including cardiopulmonary failure, data from 1,975 inpatient stays were analyzed. Patients who received mechanical ventilation within 2 days of admission were compared to those who did not. Univariable and multivariable logistic regression analyses were performed to identify clinical factors associated with in-hospital mortality.
Of 162 patients who received endotracheal intubation during the first 2 hospital days, 64 (40%) died during their hospitalization, in comparison to 336 (19%) of 1,813 patients in the comparator group. In multivariable logistic regression analysis, mechanical ventilation was the strongest predictor of in-hospital mortality in our primary analysis (adjusted odds ratio, 3.00; 95% confidence interval, 2.14-4.20; P<0.001) and in all sensitivity analyses.
Mechanical ventilation for the sole purpose of airway protection among patients with cirrhosis and grade IV hepatic encephalopathy may be associated with increased in-hospital mortality. Future studies are necessary to confirm and further characterize our findings.
患有中毒性代谢性脑病的无反应患者常因预防误吸事件这一主要目的而接受气管插管。然而，在已有全身性合并症的患者中，机械通气本身可能与诸多风险相关，如低血压、误吸、谵妄和感染。我们的主要目的是确定早期进行机械通气以保护气道是否会增加肝硬化合并IV级肝性脑病患者的死亡率。
查询2016年至2019年间因肝硬化合并IV级肝性脑病住院的全国住院患者样本。在应用我们的排除标准（包括心肺衰竭）后，分析了1975例住院患者的数据。将入院后2天内接受机械通气的患者与未接受机械通气的患者进行比较。进行单变量和多变量逻辑回归分析以确定与住院死亡率相关的临床因素。
在入院后头2天接受气管插管的162例患者中，64例（40%）在住院期间死亡，相比之下，对照组1813例患者中有336例（19%）死亡。在多变量逻辑回归分析中，在我们的主要分析以及所有敏感性分析中，机械通气都是住院死亡率的最强预测因素（调整后的优势比为3.00；95%置信区间为2.14 - 4.20；P<0.001）。
对于肝硬化合并IV级肝性脑病患者，仅为保护气道而进行机械通气可能会增加住院死亡率。未来有必要进行研究以证实并进一步明确我们的研究结果。
