Early diagnosis of sepsis-related hepatic dysfunction and its prognostic impact on survival: a prospective study with the LiMAx test.

INTRODUCTION: Liver dysfunction can derive from severe sepsis and might be associated with poor prognosis. However, diagnosis of septic liver dysfunction is challenging due to a lack of appropriate tests. Measurement of maximal liver function capacity (LiMAx test) has been successfully evaluated as a new diagnostic test in liver resection and transplantation. The aim of this study was to evaluate the LiMAx test during sepsis in comparison to biochemical tests and the indocyanin green test (ICG-PDR). METHODS: We prospectively investigated 28 patients (8 female and 20 male, age range 35 to 80 years) suffering from sepsis on a surgical ICU. All patients received routine resuscitation from septic shock (surgery, fluids, catecholamines, antibiotic drugs). The first LiMAx test and ICG-PDR were carried out within the first 24 hours after onset of septic symptoms, followed by day 2, 5 and 10. Other biochemical parameters and scores determining the severity of illness were measured daily. Clinical outcome parameters were examined after 90 days or at the end of treatment. The population was divided into 2 groups (group A: non-survivors or ICU length of stay (ICU-LOS) >30 days versus group B: survivors and ICU-LOS <30 days) for analysis. RESULTS: Epidemiological baseline characteristics of both groups were similar. Group A patients had significant lower LiMAx and ICG-PDR values than patients in group B. Determination of ICG-PDR by finger probe failed in 14.3% of tests due to insufficient peripheral pulses. Respiratory, renal and hepatic dysfunction (LiMAx and ICG-PDR) were associated with prolonged ICU-LOS. Only LiMAx <100 µg/kg/h and respiratory dysfunction were associated with increased mortality. For LiMAx <100 µg/kg/h receiver operating characteristic-analysis revealed a 100% sensitivity and 77% specificity for death. CONCLUSIONS: Sepsis-related hepatic dysfunction can be diagnosed early and effectively by the LiMAx test. The extent of LiMAx impairment is predictive for patient morbidity and mortality. The sensitivity and specificity of the LiMAx test was superior to that of ICG-PDR regarding the prediction of mortality.

Correlation between plasma endothelin-1 levels and severity of septic liver failure quantified by maximal liver function capacity (LiMAx test). A prospective study.

AIM: To investigate the relationship between the degree of liver dysfunction, quantified by maximal liver function capacity (LiMAx test) and endothelin-1, TNF-α and IL-6 in septic surgical patients. METHODS: 28 septic patients (8 female, 20 male, age range 35-80y) were prospectively investigated on a surgical intensive care unit. Liver function, defined by LiMAx test, and measurements of plasma levels of endothelin-1, TNF-α and IL-6 were carried out within the first 24 hours after onset of septic symptoms, followed by day 2, 5 and 10. Patients were divided into 2 groups (group A: LiMAx ≥100 µg/kg/h, moderate liver dysfunction; group B: LiMAx <100 µg/kg/h, severe liver dysfunction) for analysis and investigated regarding the correlation between endothelin-1 and the severity of liver failure, quantified by LiMAx test. RESULTS: Group B showed significant higher results for endothelin-1 than patients in group A (P = 0.01, d5; 0.02, d10). For TNF-α, group B revealed higher results than group A, with a significant difference on day 10 (P = 0.005). IL-6 showed a non-significant trend to higher results in group B. The Spearman's rank correlation coefficient revealed a significant correlation between LiMAx and endothelin-1 (-0.434; P <0.001), TNF-α (-0.515; P <0.001) and IL-6 (-0.590; P <0.001). CONCLUSIONS: Sepsis-related hepatic dysfunction is associated with elevated plasma levels of endothelin-1, TNF-α and IL-6. Low LiMAx results combined with increased endothelin-1 and TNF-α and a favourable correlation between LiMAx and cytokine values support the findings of a crucial role of Endothelin-1 and TNF-α in development of septic liver failure.

The obesity paradox in surgical intensive care patients with peritonitis.

PURPOSE: Although obesity is usually regarded as a risk factor in surgical patients, various observations have revealed a better outcome in the obese. This finding is called the obesity paradox. To which group of patients the paradox applies and even whether it exists at all are matters of controversial discussion. MATERIALS AND METHODS: We retrospectively analyzed 253 consecutive patients with surgical peritonitis and sepsis who needed intensive care for more than 2 days postoperative. Patients were assigned to groups according to body mass index (BMI), and groups were compared with respect to outcome parameters. RESULTS: In the 4 BMI groups--less than 21, 21 to 25, 26 to 30, and more than 30 kg/m(2)--mortality rate at 28 days was 73%, 50%, 42%, and 31%, respectively. The relative risk of death at 28 days in the BMI greater than 30 kg/m(2) group compared to the normal weight group (BMI, 21-25.9 kg/m(2)) was 0.66 (95% confidence interval, 0.28-0.94). However, mortality rate at 5 years was 90%, 70%, 69%, and 75%, respectively. Patients in the lowest BMI range were less likely to be discharged home. Intensive care unit and hospital length of stay was longest in the group of highest BMI, and that group had the best mean survival (386 days for BMI >30 kg/m(2) vs 113 days for BMI <21 kg/m(2)). CONCLUSIONS: The "obesity paradox" may exist in patients with surgical peritonitis. Short-term but not long-term outcomes were improved in the obese. Concerns about obesity as a special risk factor in patients with peritonitis are not warranted according to our findings.