title: The impact of chronic liver disease on critically ill patients
Creators: name: Soulsby, Charlotte Rebecca
Publisher: name: University of Glasgow
Year: 2019
Subjects: subject: Liver, chronic, critical illness, intensive care.

description: In the UK, mortality from liver disease has increased by 400% between 1970 and 2010 with death rates for those under 65 having risen by almost 500% (1). Up to 75% of deaths related to chronic liver disease have an underlying aetiology of alcohol and are preventable (1, 2). Advanced chronic liver disease leads to multi-system clinical manifestations, many of which will require critical care. Evidence supporting this claim is seen in the increase in admissions to critical care for those patients with cirrhosis (3). These patients have higher rates of readmission to ICU (Intensive Care Unit), longer length of ICU stay and have an increased requirement for organ support (4). Despite this, both ICU and hospital mortality in those with cirrhosis have improved since the 1980s where mortality was reported to be up to 100% (5-7). With fewer beds compared to the USA or other European countries the existing demand on critical care capacity in the UK is increasing. There remains a need for a greater number of centres offering both critical care and hepatology input, with a significant number of hospitals nationwide lacking any hepatology input (8). Assessment of critically ill patients with cirrhosis is challenging, with many prognostic scoring systems in use. To date, no scoring system has been demonstrated to be superior in stratifying which patients would benefit from ICU admission. With the existing pressure on limited critical care beds within the UK and the increased demand to support critically ill patients, identifying those patients who merit admission to critical care will become an increasingly important challenge. This thesis focuses on the factors used in the decision to admit a patient with advanced chronic liver disease or cirrhosis to critical care, their long-term survival and quality of life. Attention is given to the utility of the Child-Pugh score and when it should be assessed. As the majority of deaths due to chronic liver disease have an underlying aetiology of alcohol, this thesis will also address how an alcohol use disorder can be assessed in the critically ill. The first investigation of this thesis explores the criteria used in the decision to escalate a patient to intensive care. This is explored through 2 Scottish surveys of consultant gastroenterologists and intensivists. Results highlighted agreement by both specialities on the importance of Child-Pugh score measured when a patient was clinically stable. Inconsistencies were evident in the escalation of therapy with intensivists more likely to offer intensive care and multi-organ support as compared to gastroenterologists. In response to these findings, the timing and utility of Child-Pugh score was investigated. This observational cohort study compared Child-Pugh score measured on ICU admission with the score when a patient was clinically stable and short-term mortality. Only Child-Pugh score measured at time of ICU admission was associated with hospital mortality, which contradicted the findings of the previous chapter. The degree of change in Child-Pugh score between these time points was associated with mortality. Given that the majority of deaths due to chronic liver disease in the UK are primarily caused by alcohol, challenges exist in identifying alcohol use disorders in the critically ill. A prospective study examined the use of a proxy to report an alcohol use disorder in critically ill patients and suggested that a proxy could be used as a reliable historian. Whilst short-term survival of critically ill cirrhotics has improved, there is a paucity of studies reporting long-term outcomes. An observational cohort study investigated survival at 12 months for cirrhotic patients admitted to a general ICU in the UK. Long-term survival following an ICU stay has improved, in keeping with other studies. When measured on admission to ICU, Child-Pugh class was demonstrated to stratify patients into 3 distinct groups for long-term survival. With the improvement in survival, the sequelae of an ICU stay were investigated. A prospective observational cohort study explored the long-term quality of life and prevalence of sleep disturbance. A number of survivors reported that their quality of life was worse than, or equal to death. Quality of life and sleep disturbance were influenced by pre-existing comorbidity and events during their ICU. In this study, there was no association found between QOL and insomnia in those with liver cirrhosis. This thesis addresses the decision to admit a patient with advanced chronic liver disease or cirrhosis to critical care, reports their long-term survival and quality of life and explores how one preventable cause of chronic liver disease can be assessed in the critically ill by use of a proxy.