[Evaluation and treatment of the critically ill cirrhotic patient]. / Evaluación y tratamiento del paciente cirrótico crítico.

Cirrhotic patients often develop severe complications requiring ICU admission. Grade III-IV hepatic encephalopathy, septic shock, acute-on-chronic liver failure and variceal bleeding are clinical decompensations that need a specific therapeutic approach in cirrhosis. The increased effectiveness of the treatments currently used in this setting and the spread of liver transplantation programs have substantially improved the prognosis of critically ill cirrhotic patients, which has facilitated their admission to critical care units. However, gastroenterologists and intensivists have limited knowledge of the pathogenesis, diagnosis and treatment of these complications and of the prognostic evaluation of critically ill cirrhotic patients. Cirrhotic patients present alterations in systemic and splanchnic hemodynamics, coagulation and immune dysfunction what further increase the complexity of the treatment, the risk of developing new complications and mortality in comparison with the general population. These differential characteristics have important diagnostic and therapeutic implications that must be known by general intensivists. In this context, the Catalan Society of Gastroenterology and Hepatology requested a group of experts to draft a position paper on the assessment and treatment of critically ill cirrhotic patients. This article describes the recommendations agreed upon at the consensus meetings and their main conclusions.

Impact of physician specialty on the cost of nonvariceal upper GI bleeding care.

OBJECTIVE: Upper GI bleeding (UGIB) is a common medical emergency that leads to a high consumption of medical resources and costs. We aimed to analyze the influence of physician specialty on the costs of nonvariceal UGIB care. METHODS: We retrospectively assessed 350 nonvariceal UGIB episodes that were primarily cared for by gastroenterologists (n = 142), internists (n = 67), or surgeons (n = 141). Gastroenterologists followed evidence-based clinical protocols that included early endoscopy and early hospital discharge for uncomplicated bleeding. A risk score system was used to control for severity of illness. Linear regression analyses were performed to find out predictors of costs and the influence of specialist care on length of stay (LOS). RESULTS: The overall mean hospital cost was significantly lower in patients cared for by gastroenterologists (EUR 1,630) than in those managed by internists (EUR 3,745, p < 0.001) or surgeons (EUR 2,513, p < 0.05). The mean LOS was the variable with highest influence on total cost. Patients cared for by gastroenterologists had a mean LOS significantly shorter (7.3 days) than that of those treated by internists (16.2 days, p < 0.001) or surgeons (11 days, p < 0.001). Hospital costs and LOS differences were maintained when adjusting for severity of illness. In caring for low risk patients, nongastroenterologists had a higher probability of having a hospital stay longer than 4 days (odds ratio = 18.4, Cl = 4.6-73.6, p < 0.001). CONCLUSION: The implementation of specific evidence-based protocols by gastroenterologists reduces length of hospital stay and saves medical costs in patients with nonvariceal UGIB, especially those at low risk.