Sequential Organ Failure Assessment (SOFA) score

Model for end-stage liver disease score(MELD)

—MELD(Model for end-stage liver disease) score   
計算公式：

 MELD Score = (0.957 * ln(Serum Cr) + 0.378 * ln(Serum Bilirubin) + 1.120 * ln(INR) + 0.643 ) * 10 (if hemodialysis, value for Creatinine is automatically set to 4.0)

the 3 month mortality is: [6]

—40 or more — 71.3% mortality

—30–39 — 52.6% mortality

—20–29 — 19.6% mortality

—10–19 — 6.0% mortality

—<9 — 1.9% mortality

Source from http://en.wikipedia.org/wiki/Model_for_End-Stage_Liver_Disease

Pre-operative usage of molecular adsorbent re-circulating system (MARS)

—MARS（Molecular Adsorbent Recycling System）

是一種新型人工肝臟支持系統，目的為延長等待時間增加急性肝衰竭患者接受肝臟移植手術的機會。該系統將血液引流到體外，血液的毒素經由特殊的透析膜，被另一側循環的白蛋白溶液吸附帶走，經過透析、活性碳吸附、樹脂吸附，乾淨的白蛋白溶液再循環重複使用。其毒素移除效果好，不良反應少。處理後的乾淨血液回輸患者體內，每次治療約需6至8小時，一般治療期間需每天或每2天洗1次，不過費用高昂，每洗1次約需15至20萬元，健保並未給付。

CTP(Child-Turcotte-Pugh)

Measure	1 point	2 points	3 points
Total bilirubin, μmol/l (mg/dl)	<34 (<2)	34-50 (2-3)	>50 (>3)
Serum albumin, g/l	>35	28-35	<28
PT INR	<1.7	1.71-2.30	> 2.30
Ascites	None	Mild	Moderate to Severe
Hepatic encephalopathy	None	Grade I-II (or suppressed with medication)	Grade III-IV (or refractory)

Points	Class	One year survival	Two year survival
5-6	A	100%	85%
7-9	B	81%	57%
10-15	C	45%	35%

source from: http://en.wikipedia.org/wiki/Child-Pugh_score

Cuff-leak test for the diagnosis of upper airway obstruction in adults: a systematic review and meta-analysis

Maria Elena Ochoa, Maria del Carmen Marı´n, Fernando Frutos-Vivar, Federico Gordo, Jaime Latour-Pe´rez, Enrique Calvo, Andres Esteban   

Intensive Care Med (2009) 35(7):1171-9

報告者：廖瑞琪 101.12.19

Abstract

Purpose:

To evaluate, in adults, the diagnostic accuracy of the cuff-leak test for the diagnosis of upper airway obstruction secondary to laryngeal edema and for reintubation secondary to upper airway obstruction.

Methods:

Systematic review without language restrictions based on electronic databases and manual review of the literature up to December 2008. When appropriate, a random-effects meta-analysis and meta-regression (Moses’ method) were performed.

Results:

Upper airway obstruction was the outcome in nine studies with an overall incidence of 6.9%. There was significant heterogeneity among studies. The pooled sensitivity was 0.56 (95% confidence interval: 0.48–0.63), the specificity was 0.92 (95% CI: 0.90–0.93), the positive likelihood ratio was 5.90 (95% CI: 4.00–8.69), the negative likelihood ratio was 0.48 (95% CI: 0.33–0.72), and the diagnostic odds ratio was 18.78 (95% CI:7.36–47.92). The area under the curve of the summary receiver-operator characteristic (SROC) was 0.92 (95% CI: 0.89–0.94). Only three studies have evaluated the accuracy of the cuff-leak test for reintubation secondary to upper airway obstruction. Overall incidence was 7%. The pooled sensitivity was 0.63 (95% CI: 0.38–0.84), the specificity was 0.86 (95% CI: 0.81–0.90), the positive likelihood ratio was 4.04 (95% CI:2.21–7.40), the negative likelihood ratio was 0.46 (95% CI: 0.26–0.82), and the diagnostic odds ratio was 10.37 (95% CI: 3.70–29.13).

Conclusions:

A positive cuff-leak test (absence of leak) should alert the clinician of a high risk of upper airway obstruction.

Pre-Operative Risk Factors Predict Post-Operative Respiratory Failure after Liver Transplantation

Ching-Tzu Huang., Horng-Chyuan Lin, Shi-Chuan Chang, Wei-Chen Lee   

PLoS ONE 2011,6(8): e22689

報告者：郭小萍 101.12.12

Abstract

Objective:

Post-operative pulmonary complications significantly affect patient survival rates, but there is still no conclusive evidence regarding the effect of post-operative respiratory failure after liver transplantation on patient prognosis. This study aimed to predict the risk factors for post-operative respiratory failure (PRF) after liver transplantation and the impact on short-term survival rates.

Design:

The retrospective observational cohort study was conducted in a twelve-bed adult surgical intensive care unit in northern Taiwan. The medical records of 147 liver transplant patients were reviewed from September 2002 to July 2007. Sixty-two experienced post-operative respiratory failure while the remaining 85 patients did not.

Measurements and Main Results:

Gender, age, etiology, disease history, pre-operative ventilator use, molecular adsorbent re-circulating system (MARS) use, source of organ transplantation, model for end-stage liver disease score (MELD) and Child-Turcotte-Pugh score calculated immediately before surgery were assessed for the two groups. The length of the intensive care unit stay, admission duration, and mortality within 30 days, 3 months, and 1 year were also evaluated. Using a logistic regression model, post-operative respiratory failure correlated with diabetes mellitus prior to liver transplantation, preoperative impaired renal function, pre-operative ventilator use, pre-operative MARS use and deceased donor source of organ transplantation (p<0.05). Once liver transplant patients developed PRF, their length of ICU stay and admission duration were prolonged, significantly increasing their mortality and morbidity (p<0.001).

Conclusions:

The predictive pre-operative risk factors significantly influenced the occurrence of post-operative respiratory failure after liver transplantation.

Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients (Review)

Blackwood B, Alderdice F, Burns KEA, Cardwell CR, Lavery G, O’Halloran P

The Cochrane Library 2011, Issue 7

報告者：林美妙 101.12.5

A B S T R A C T

Background

Reducing weaning time is desirable in minimizing potential complications from mechanical ventilation. Standardized weaning protocols are purported to reduce time spent on mechanical ventilation. However, evidence supporting their use in clinical practice is inconsistent.

Objectives

To assess the effects of protocolized weaning from mechanical ventilation on the total duration of mechanical ventilation for critically ill adults; ascertain differences between protocolized and non-protocolized weaning in terms of mortality, adverse events, quality of life, weaning duration, intensive care unit (ICU) and hospital length of stay (LOS); and explore variation in outcomes by type of ICU, type of protocol and approach to delivering the protocol.

Search methods

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2010), MEDLINE (1950 to 2010), EMBASE (1988 to 2010), CINAHL (1937 to 2010), LILACS (1982 to 2010), ISI Web of Science and ISI Conference Proceedings (1970 to 2010), Cambridge Scientific Abstracts (inception to 2010) and reference lists of articles. We did not apply language restrictions.

Selection criteria

We included randomized and quasi-randomized controlled trials of protocolized weaning versus non-protocolized weaning from mechanical ventilation in critically ill adults.

Data collection and analysis

Three authors independently assessed trial quality and extracted data. A priori subgroup and sensitivity analyses were performed. We contacted study authors for additional information.

Main results

Eleven trials that included 1971 patients met the inclusion criteria. The total duration of mechanical ventilation geometric mean in the protocolized weaning group was on average reduced by 25% compared with the usual care group (N = 10 trials, 95% CI 9% to 39%, P = 0.006); weaning duration was reduced by 78% (N = 6 trials, 95% CI 31% to 93%, P = 0.009); and ICU LOS by 10% (N = 8 trials, 95% CI 2% to 19%, P = 0.02). There was significant heterogeneity among studies for total duration of mechanical ventilation (I² = 76%, P < 0.01) and weaning duration (I² = 97%, P < 0.01), which could not be explained by subgroup analyses based on type of unit or type of approach.

Authors’ conclusions

There is some evidence of a reduction in the duration of mechanical ventilation, weaning duration and ICU LOS with use of standardized protocols, but there is significant heterogeneity among studies and an insufficient number of studies to investigate the source of this heterogeneity. Although some study authors suggest that organizational context may influence outcomes, these factors were not considered in all included studies and therefore could not be evaluated.