Failure to rescue in acute liver failure: A multicenter cohort study.

Introduction: The concept of failure to rescue has been used to measure the quality of care for complications developed following surgery. The concept of failure to rescue has been poorly studied in patients with primary medical diseases, such as sepsis or acute liver failure (ALF).

Methods: Retrospective multicenter cohort including consecutive patients with ALF within the United States ALF Study Group (USALFSG) prospective registry from 2010 to 2016. The failure to rescue rate for 12 medical complications in the registry was calculated as the mortality events up to 21 days post inclusion divided by the complication events registered on the first day post inclusion. The association between these complications and 21-day transplant-free mortality was studied.

Results: Among 665 patients with ALF, 478 (71.9%) were females and median (IQR) age was 42 (30-55) years. Acetaminophen intoxication was observed in 322 (48.4%) patients. Overall, 461 (69.3%) patients had at least one medical complication on the first day post inclusion (median (IQR) number of 1 (0-3)). The failure to rescue rate for the 12 complications was 32.8%. The complications with the higher failure to rescue rates were gastro-intestinal bleed (63.6%), non-gastro-intestinal bleed (53.9%), requirement for vasopressors (52.5%), and acute respiratory distress syndrome (48.1%). After adjusting for age, sex, etiology, and INR, per each added complication present on day one, the odds of 21-day transplant-free mortality increased 38% (aOR (95%CI) of 1.38 (1.24-1.54); c-statistic (95%CI) of 0.77 (0.73-0.81)).

Conclusions: In patients with ALF, the concept of failure to rescue highlights the need to improve prevention, early detection, and timely management of medical complications developing early in the hospital stay.