Bleeding complications in critically ill patients with liver cirrhosis
0
조회
0
다운로드
0
인용
0
참고문헌
키워드
초록
Background/Aims: Patients with liver cirrhosis (LC) are at risk for critical events leading to Intensive Care Unit (ICU) admission. Coagulopathy in cirrhotic patients is complex and can lead to bleeding as well as thrombosis. The aim of this study was to investigate bleeding complications in critically ill patients with LC admitted to a medical ICU (MICU). Methods: All adult patients admitted to our MICU with a diagnosis of LC from January 2006 to December 2012 were retrospectively assessed. Patients with major bleeding at the time of MICU admission were excluded from the analysis. Results: A total of 205 patients were included in the analysis. The median patient age was 62 years, and 69.3% of the patients were male. The most common reason for MICU admission was acute respiratory failure (45.4%), followed by sepsis (27.3%). Major bleeding occurred in 25 patients (12.2%). The gastrointestinal tract was the most common site of bleeding (64%), followed by the respiratory tract (20%). In a multivariate analysis, a low platelet count at MICU admission (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.97 to 0.99) and sepsis (OR, 8.35; 95% CI, 1.04 to 67.05) were independent risk factors for major bleeding. The ICU fatality rate was significantly greater among patients with major bleeding (84.0% vs. 58.9%, respectively; p = 0.015). Conclusions: Major bleeding occurred in 12.2% of critically ill cirrhotic patients admitted to the MICU. A low platelet count at MICU admission and sepsis were associated with an increased risk of major bleeding during the MICU stay. Further study is needed to better understand hemostasis in critically ill patients with LC.
Abstract
Background/Aims: Patients with liver cirrhosis (LC) are at risk for critical events leading to Intensive Care Unit (ICU) admission. Coagulopathy in cirrhotic patients is complex and can lead to bleeding as well as thrombosis. The aim of this study was to investigate bleeding complications in critically ill patients with LC admitted to a medical ICU (MICU). Methods: All adult patients admitted to our MICU with a diagnosis of LC from January 2006 to December 2012 were retrospectively assessed. Patients with major bleeding at the time of MICU admission were excluded from the analysis. Results: A total of 205 patients were included in the analysis. The median patient age was 62 years, and 69.3% of the patients were male. The most common reason for MICU admission was acute respiratory failure (45.4%), followed by sepsis (27.3%). Major bleeding occurred in 25 patients (12.2%). The gastrointestinal tract was the most common site of bleeding (64%), followed by the respiratory tract (20%). In a multivariate analysis, a low platelet count at MICU admission (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.97 to 0.99) and sepsis (OR, 8.35; 95% CI, 1.04 to 67.05) were independent risk factors for major bleeding. The ICU fatality rate was significantly greater among patients with major bleeding (84.0% vs. 58.9%, respectively; p = 0.015). Conclusions: Major bleeding occurred in 12.2% of critically ill cirrhotic patients admitted to the MICU. A low platelet count at MICU admission and sepsis were associated with an increased risk of major bleeding during the MICU stay. Further study is needed to better understand hemostasis in critically ill patients with LC.
참고문헌 (29)
- Yang ZJ, "Venous thromboembolism in cirrhosis", Clin Appl Thromb Hemost, 20, pp.169~178 (2014)
- Northup PG, "Coagulopathy does not fully protect hospitalized cirrhosis patients from peripheral venous thromboembolism", Am J Gastroenterol, 101, pp.1524~1528 (2006)
- Dabbagh O, "Coagulopathy does not protect against venous thromboembolism in hospitalized patients with chronic liver disease", Chest, 137, pp.1145~1149 (2010)
- Sogaard KK, "Risk of venous thromboembolism in patients with liver disease: a nationwide population-based case-control study", Am J Gastroenterol, 104, pp.96~101 (2009)
- Tripodi A, "The coagulopathy of chronic liver disease", N Engl J Med, 365, pp.147~156 (2011)
- Tufano A, "Prevention of venous thromboembolism in medical patients with thrombocytopenia or with platelet dysfunction: a review of the literature", Semin Thromb Hemost, 37, pp.267~274 (2011)
- Walsh KA, "Risk factors for venous thromboembolism in patients with chronic liver disease", Ann Pharmacother, 47, pp.333~339 (2013)
- Delgado MG, "Efficacy and safety of anticoagulation on patients with cirrhosis and portal vein thrombosis", Clin Gastroenterol Hepatol, 10, pp.776~783 (2012)
- Rodriguez-Castro KI, "Anticoagulation for the treatment of thrombotic complications in patients with cirrhosis", Liver Int, 32, pp.1465~1476 (2012)
- Roberts LN, "Haemostasis and thrombosis in liver disease", Br J Haematol, 148, pp.507~521 (2010)
- Arnold DM, "Bleeding during critical illness: a prospective cohort study using a new measurement tool", Clin Invest Med, 30, pp.E93~E102 (2007)
- Arnold DM, "Adjudication of bleeding outcomes in an international thromboprophylaxis trial in critical illness", Thromb Res, 131, pp.204~209 (2013)
- Benvegnu L, "Natural history of compensated viral cirrhosis: a prospective study on the incidence and hierarchy of major complications", Gut, 53, pp.744~749 (2004)
- Gines P, "Management of critically-ill cirrhotic patients", J Hepatol, 56(Suppl 1), pp.S13~S24 (2012)
- Rudler M, "Peptic ulcer bleeding in patients with or without cirrhosis: different diseases but the same prognosis?", Aliment Pharmacol Ther, 36, pp.166~172 (2012)
- Caldwell SH, "Coagulation disorders and hemostasis in liver disease: pathophysiology and critical assessment of current management", Hepatology, 44, pp.1039~1046 (2006)
- Bernard B, "Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis", Hepatology, 29, pp.1655~1661 (1999)
- Bleichner G, "Frequency of infections in cirrhotic patients presenting with acute gastrointestinal haemorrhage", Br J Surg, 73, pp.724~726 (1986)
- Vincent JL, "Platelet function in sepsis", Crit Care Med, 30(5 Suppl), pp.S313~S317 (2002)
- Montalto P, "Bacterial infection in cirrhosis impairs coagulation by a heparin effect: a prospective study", J Hepatol, 37, pp.463~470 (2002)
- Tripodi A, "Thrombin generation in patients with cirrhosis: the role of platelets", Hepatology, 44, pp.440~445 (2006)
- Kahn SR, "Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines", Chest, 141(2 Suppl), pp.e195S~e226S (2012)
- Villa E, "Enoxaparin prevents portal vein thrombosis and liver decompensation in patients with advanced cirrhosis", Gastroenterology, 143, pp.1253~1260.e1-e4 (2012)
- Aldawood A, "The incidence of venous thromboembolism and practice of deep venous thrombosis prophylaxis in hospitalized cirrhotic patients", Thromb J, 9, pp.1~ (2011)
- Northup PG, "Coagulation in liver disease:a guide for the clinician", Clin Gastroenterol Hepatol, 11, pp.1064~1074 (2013)
- Gulley D, "Deep vein thrombosis and pulmonary embolism in cirrhosis patients", Dig Dis Sci, 53, pp.3012~3017 (2008)
- Violi F, "Bleeding time in patients with cirrhosis: relation with degree of liver failure and clotting abnormalities: C.A.L.C. Group. Coagulation Abnormalities in Cirrhosis Study Group", J Hepatol, 20, pp.531~536 (1994)
- Boberg KM, "Is a prolonged bleeding time associated with an increased risk of hemorrhage after liver biopsy?", Thromb Haemost, 81, pp.378~381 (1999)
- de Franchis R, "Randomized controlled trial of desmopressin plus terlipressin vs. terlipressin alone for the treatment of acute variceal hemorrhage in cirrhotic patients: a multicenter, double-blind study. New Italian Endoscopic Club", Hepatology, 18, pp.1102~1107 (1993)