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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.
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