Thromboelastography Parameters Are Associated with Cirrhosis Severity.

BACKGROUND: Coagulopathy in cirrhosis represents complex coagulation derangements, and thromboelastography (TEG) measures these complex derangements. AIM: We sought to evaluate associations between TEG parameters and validated measures of cirrhosis severity, which have not been previously investigated. MATERIALS AND METHODS: Adults with cirrhosis undergoing liver transplant (LT) were identified. Patients had TEG drawn immediately prior to LT. TEG parameters included reaction time (R), kinetic time (K), alpha angle (α), and maximum amplitude (MA). The validated measures of cirrhosis severity were MELD-Na and clinical stage of cirrhosis (classified using history of varices, variceal bleeding, or ascites). Multivariable linear and logistic regression analyses were conducted to evaluate the associations between TEG and stage of cirrhosis and MELD-Na. RESULTS: Among 164 patients with cirrhosis, advancing stage of cirrhosis was associated with more hypocoagulable TEG parameters including longer K-time (p = 0.05) and lower MA (p < 0.001). Similarly, with increasing MELD-Na quartiles, K-time was longer (p < 0.001), and both MA and α-angle decreased (p < 0.001, for both). Variceal bleeding within 6 weeks prior to LT was associated with longer R-times (p = 0.02), longer K-times (p = 0.04), smaller α-angle (p = 0.03), and lower MA (p = 0.01). On multivariable analyses, decreasing MA remained statistically significantly associated with advancing stage of cirrhosis and increasing MELD-Na, after adjusting for multiple covariates including platelet count, (p = 0.02 and p < 0.0001, respectively). CONCLUSIONS: Hypocoagulable TEG measurements are associated with advancing stage of cirrhosis and increasing MELD-Na among patients with cirrhosis. These data indicate that TEG, as an informative measure of complex hemostatic function, may be a useful objective marker of liver disease severity in cirrhosis.

Rate and predictors of successful cardiopulmonary resuscitation in end-stage liver disease.

BACKGROUND: Cardiopulmonary resuscitation (CPR) after cardiac arrest in terminally ill patients is controversial. End-stage liver disease (ESLD) patients are unique from other terminally ill as they are generally younger and may be candidates for curative liver transplantation, but multiple studies have suggested poor outcomes when these patients require CPR. Predictors of success of CPR in ESLD have not been fully investigated, limiting end-of-life discussions. AIM: The aim of this study was to quantify the rate and predictors of successful CPR in ESLD. METHODS: We performed a retrospective chart review of patients with ESLD who received CPR from 2/2002 to 12/2013 at a single institution. Pre-cardiac arrest variables were collected for analysis as predictors of survival. Our primary outcome was survival to hospital discharge. RESULTS: Of the 38 patients who underwent CPR, six survived to hospital discharge. When comparing those who survived to discharge with those who did not, we found no significant difference in age (p = 0.34), gender (p = 0.85), presence of ascites (p = 0.67), location at time of arrest (p = 0.39), concurrent GI bleeding (p = 0.48), and multiple individual lab values. Significant predictors of not surviving to hospital discharge were a model for end-stage liver disease (MELD) ≥ 20 (OR 6.0, p = 0.044) and presentation with a non-shockable rhythm (PEA/asystole) (OR 29, p < 0.001). CONCLUSION: ESLD patients requiring CPR have worse outcomes as their MELD score increases. CPR in ESLD when MELD is <20 or with a shockable rhythm has a greater likelihood of success.

Post-extubation dysphagia is associated with longer hospitalization in survivors of critical illness with neurologic impairment.

INTRODUCTION: Critically ill patients can develop acute respiratory failure requiring endotracheal intubation. Swallowing dysfunction after liberation from mechanical ventilation, also known as post-extubation dysphagia, is common and deleterious among patients without neurologic disease. However, the risk factors associated with the development of post-extubation dysphagia and its effect on hospital lengthofstay in critically ill patients with neurologic disorders remains relatively unexplored. METHODS: We conducted a retrospective, observational cohort study from 2008 to 2010 of patients with neurologic impairment who required mechanical ventilation and subsequently received a bedside swallow evaluation (BSE) by a speech-language pathologist. RESULTS: A BSE was performed after mechanical ventilation in 25% (630/2,484) of all patients. In the 184 patients with neurologic impairment, post-extubation dysphagia was present in 93% (171/184), and was classified as mild, moderate, or severe in 34% (62/184), 26% (48/184), and 33% (61/184), respectively. In univariate analyses, statistically significant risk factors for moderate/severe dysphagia included longer durations of mechanical ventilation and the presence of a tracheostomy. In multivariate analysis, adjusting for age, tracheostomy, cerebrovascular disease, and severity of illness, mechanical ventilation for >7 days remained independently associated with moderate/severe dysphagia (adjusted odds ratio=4.48 (95%confidence interval=2.14 to 9.81), P<0.01). The presence of moderate/severe dysphagia was also significantly associated with prolonged hospital lengthofstay, discharge status, and surgical placement of feeding tubes. When adjusting for age, severity of illness, and tracheostomy, patients with moderate/severe dysphagia stayed in the hospital 4.32 days longer after their initial BSE than patients with none/mild dysphagia (95% confidence interval=3.04 to 5.60 days, P<0.01). CONCLUSION: In a cohort of critically ill patients with neurologic impairment, longer duration of mechanical ventilation is independently associated with post-extubation dysphagia, and the development of post-extubation dysphagia is independently associated with a longer hospital length of stay after the initial BSE.

Growth differentiation factor-15 and prognosis in acute respiratory distress syndrome: a retrospective cohort study.

INTRODUCTION: We sought to determine whether higher levels of the novel biomarker growth differentiation factor-15 (GDF-15) are associated with poor outcomes and the presence of pulmonary vascular dysfunction (PVD) in patients with acute respiratory distress syndrome (ARDS). METHODS: We conducted a retrospective cohort study in patients enrolled in the Acute Respiratory Distress Syndrome Network Fluid and Catheter Treatment (FACT) Trial. Patients enrolled in the FACT Trial who received a pulmonary artery catheter (PAC), had plasma available from the same study day and sufficient hemodynamic data to determine the presence of PVD were included. Logistic regression was used to determine the association between GDF-15 level and 60-day mortality. RESULTS: Of the 513 patients enrolled in the FACT Trial assigned to receive a PAC, 400 were included in this analysis. Mortality at 60 days was significantly higher in patients whose GDF-15 levels were in the third (28%) or fourth (49%) quartile when compared to patients with GDF-15 levels in the first quartile (12%) (P <0.001). Adjusting for severity of illness measured by APACHE III score, the odds of death for patients with GDF-15 levels in the fourth quartile when compared to the first quartile was 4.26 (95% CI 2.18, 10.92, P <0.001). When added to APACHE III alone for prediction of 60-day mortality, GDF-15 levels increased the area under the receiver operating characteristic curve from 0.72 to 0.77. At an optimal cutoff of 8,103 pg/mL, the sensitivity and specificity of GDF-15 for predicting 60-day mortality were 62% (95% CI 53%, 71%) and 76% (95% CI 71%, 81%), respectively. Levels of GDF-15 were not useful in identifying the presence of PVD, as defined by hemodynamic measurements obtained by a PAC. CONCLUSIONS: In patients with ARDS, higher levels of GDF-15 are significantly associated with poor outcome but not PVD.

Differential effects of plasma and red blood cell transfusions on acute lung injury and infection risk following liver transplantation.

Patients with chronic liver disease have an increased risk of developing transfusion-related acute lung injury (TRALI) from plasma-containing blood products. Similarly, red blood cell transfusions have been associated with postoperative and nosocomial infections in surgical and critical care populations. Patients undergoing liver transplantation receive large amounts of cellular and plasma-containing blood components, but it is presently unclear which blood components are associated with these postoperative complications. A retrospective cohort study of 525 consecutive liver transplant patients revealed a perioperative TRALI rate of 1.3% (7/525, 95% confidence interval = 0.6%-2.7%), which was associated with increases in the hospital mortality rate [28.6% (2/7) versus 2.9% (15/518), P = 0.02] and the intensive care unit length of stay [2 (1-11 days) versus 0 days (0-2 days), P = 0.03]. Only high-plasma-containing blood products (plasma and platelets) were associated with the development of TRALI. Seventy-four of 525 patients (14.1%) developed a postoperative infection, and this was also associated with increased in-hospital mortality [10.8% (8/74) versus 2.0% (9/451), P < 0.01] and a prolonged length of stay. Multivariate logistic regression determined that the number of transfused red blood cell units (adjusted odds ratio = 1.08, 95% confidence interval = 1.02-1.14, P < 0.01), the presence of perioperative renal dysfunction, and reoperation were significantly associated with postoperative infection. In conclusion, patients undergoing liver transplantation have a high risk of developing postoperative complications from blood transfusion. Plasma-containing blood products were associated with the development of TRALI, whereas red blood cells were associated with the development of postoperative infections in a dose-dependent manner.

Postextubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness.

INTRODUCTION: Dysphagia is common among survivors of critical illness who required mechanical ventilation during treatment. The risk factors associated with the development of postextubation dysphagia, and the effects of dysphagia on patient outcomes, have been relatively unexplored. METHODS: We conducted a retrospective, observational cohort study from 2008 to 2010 of all patients over 17 years of age admitted to a university hospital ICU who required mechanical ventilation and subsequently received a bedside swallow evaluation (BSE) by a speech pathologist. RESULTS: A BSE was performed after mechanical ventilation in 25% (630 of 2,484) of all patients. After we excluded patients with stroke and/or neuromuscular disease, our study sample size was 446 patients. We found that dysphagia was present in 84% of patients (n = 374) and classified dysphagia as absent, mild, moderate or severe in 16% (n = 72), 44% (n = 195), 23% (n = 103) and 17% (n = 76), respectively. In univariate analyses, we found that statistically significant risk factors for severe dysphagia included long duration of mechanical ventilation and reintubation. In multivariate analysis, after adjusting for age, gender and severity of illness, we found that mechanical ventilation for more than seven days remained independently associated with moderate or severe dysphagia (adjusted odds ratio (AOR) = 2.84 [interquartile range (IQR) = 1.78 to 4.56]; P < 0.01). The presence of severe postextubation dysphagia was significantly associated with poor patient outcomes, including pneumonia, reintubation, in-hospital mortality, hospital length of stay, discharge status and surgical placement of feeding tubes. In multivariate analysis, we found that the presence of moderate or severe dysphagia was independently associated with the composite outcome of pneumonia, reintubation and death (AOR = 3.31 [IQR = 1.89 to 5.90]; P < 0.01). CONCLUSIONS: In a large cohort of critically ill patients, long duration of mechanical ventilation was independently associated with postextubation dysphagia, and the development of postextubation dysphagia was independently associated with poor patient outcomes.

Physical therapy management and patient outcomes following ICU-acquired weakness: a case series.

BACKGROUND AND PURPOSE: Individuals with critical illness experience dysfunction of many body systems including the neuromuscular system. Neuromuscular impairments result in a syndrome referred to as intensive care unit (ICU)-acquired weakness, which may lead to difficulty with activities and participation. The purposes of this case series were to (1) describe safety and feasibility of physical intervention in individuals with ICU-acquired weakness mechanically ventilated for at least 7 days and (2) characterize physical therapist management and patient outcomes. CASE DESCRIPTION: Nineteen patients with ICU-acquired weakness who required mechanical ventilation for at least 7 days were enrolled over a 1-year period. INTERVENTION: Physical therapy (PT) was provided 5 d/wk for 30 minutes per session. OUTCOMES: Outcome measures included manual muscle tests and item scores from the Functional Independence Measure. Participants completed 170 PT sessions. Only 20 sessions (12%) were stopped before 30 minutes. Seventeen participants survived to discharge; no PT-related adverse events occurred. At discharge, participants who went home showed a trend toward greater independence and strength than those who were discharged to another level of care. Median total hospital days was 28 for those discharged to home and 22 for those discharged to other level of care. DISCUSSION: This case series demonstrates safety and feasibility of PT intervention for patients with ICU-acquired weakness requiring mechanical ventilation for at least 7 days. The examination and intervention procedures are described and could be implemented with other similar individuals in the hospital setting. Future studies should investigate frequency and duration of physical intervention, both during hospitalization and postdischarge, and how these factors influence outcomes.

Transfusion-related acute lung injury (TRALI): a clinical review with emphasis on the critically ill.

Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-related morbidity and mortality world-wide. Although first described in 1983, it took two decades to develop consensus definitions, which remain controversial. The pathogenesis of TRALI is related to the infusion of donor antibodies that recognize leucocyte antigens in the transfused host or the infusion of lipids and other biological response modifiers that accumulate during the storage or processing of blood components. TRALI appears to be the result of at least two sequential events and treatment is supportive. This review demonstrates that critically ill patients are more susceptible to TRALI and require special attention by critical care specialists, haematologists and transfusion medicine experts. Further research is required into TRALI and its pathogenesis so that transfusions are safer and administered appropriately. Avoidance including male-only transfusion practises, the use of leucoreduced components, fresher blood/blood components and solvent detergent plasma are also discussed.

Prone positioning for acute respiratory distress syndrome.

Multiple animal and human studies have shown that prone positioning improves oxygenation and reduces ventilator-induced lung injury (VILI) in the setting of acute lung injury or acute respiratory distress syndrome (ARDS). In this article, the physiologic changes explaining the improvement in oxygenation are reviewed, how prone positioning reduces VILI is described, randomized controlled trials of prone ventilation in patients with ARDS are evaluated, the complications associated with prone ventilation are summarized, suggestions are made as to how these might be reduced or avoided, and when prone ventilation should start and stop and for what duration it should be used are discussed.

Pulmonary complications of transfused blood components.

Three transfusion complications are responsible for the majority of the morbidity and mortality in hospitalized patients. This article discusses the respiratory complications associated with these pathophysiologic processes, including definitions, diagnosis, mechanism, incidence, risk factors, clinical management, and strategies for prevention. It also explores how different patient populations and different blood components differentially affect the risk of these deadly transfusion complications. Lastly, the article discusses how health care providers can risk stratify individual patients or patient populations to determine whether a given transfusion is more likely to benefit or harm the patient based on the transfusion indication, risk, and expected result.

Diagnosis and treatment of post-extubation dysphagia: results from a national survey.

PURPOSE: This study sought to determine the utilization of speech-language pathologist (SLPs) for the diagnosis and treatment of post-extubation dysphagia in survivors of mechanical ventilation. METHODS: We designed, validated, and mailed a survey to 1,966 inpatient SLPs who routinely evaluate patients for post-extubation dysphagia. RESULTS: Most SLP diagnostic evaluations (60%; 95% CI, 59%-62%) were performed using clinical techniques with uncertain accuracy. Instrumental diagnostic tests (such as fluoroscopy and endoscopy) are more likely to be available at university than community hospitals. After adjusting for hospital size and academic affiliation, instrumental test use varied significantly by geographical region. Treatments for post-extubation dysphagia usually involved dietary adjustment (76%; 95% CI, 73-79%) and postural changes/compensatory maneuvers (86%; 95% CI, 84-88%), rather than on interventions aimed to improve swallowing function (24%; 95% CI, 21-27%). CONCLUSIONS: SLPs frequently evaluate acute respiratory failure survivors. However, diagnostic evaluations rely mainly upon bedside techniques with uncertain accuracy. The use of instrumental tests varies by geographic location and university affiliation. Current diagnostic practices and feeding decisions for critically ill patients should be viewed with caution until further studies determine the accuracy of bedside detection methods.

Transfusion-related acute lung injury in ICU patients admitted with gastrointestinal bleeding.

PURPOSE: Transfusion of blood components is common in patients admitted to the intensive care unit (ICU) for gastrointestinal (GI) bleeding, yet the incidence and risk factors for development of transfusion-related acute lung injury (TRALI) in these patients are unknown. METHODS: Patients admitted to a medical ICU for GI bleeding (n = 225) were analyzed for patient- and transfusion-specific risk factors for development of TRALI. RESULTS: In transfused patients (n = 150), the incidence of TRALI was 15% [95% confidence interval (CI), 10-21%] and accounted for 76% (22/29) of all acute lung injury (ALI) cases. Transfused patients with end-stage liver disease (ESLD) (n = 72) developed TRALI more frequently than those without ESLD (29% versus 1%, p < 0.01). Fresh frozen plasma (FFP) was temporally associated with TRALI in 86% of cases. Transfusion-specific risk factors for development of TRALI included number of transfused units of FFP and nonleukoreduced red blood cells. Patient-specific risk factors included Model for End-Stage Liver Disease (MELD) score, admission serum albumin level, and presence of ALI risk factors. CONCLUSIONS: TRALI is common in critically ill ESLD patients with gastrointestinal bleeding. Nonleukoreduced red blood cells and FFP are significant transfusion-specific risk factors and their use should be re-evaluated in bleeding patients with ESLD.