Prevention and treatment of stress ulcers in critically ill patients

Critically ill patients are at increased risk of developing stress-related mucosal lesions. The pathogenesis of stress-related mucosal disease is not entirely clear, but probably is associated with impairment of mucosal protective mechanisms due to compromised gastric mucosal microcirculation. Acid also plays an integral role. The incidence of gastrointestinal bleeding among intensive care unit patients has been declining over the past 30 years. Only a small proportion of patients with stress-related mucosal lesions develop clinically overt bleeding, and the majority of the overt bleedings do not lead to hemodynamic instability. However, the presence of gastrointestinal bleeding in a critically ill patient predicts markedly increased mortality. Prolonged mechanical ventilation and coagulopathy are the most important predictors of stress ulcer related bleeding. Critically ill patients with stress ulcer related bleeding should be managed in the acute setting just as patients presenting with upper gastrointestinal bleeding. Available evidence supports the use of stress ulcer prophylaxis in patients with risk factors for bleeding. Both histamine 2 receptor antagonists and sucralfate are effective forms of stress ulcer bleeding prophylaxis. More potent acid suppression by proton pump inhibitors may offer additional benefit in the prevention of stress ulcer bleeding.     

Prevalence and risk factors of stress-induced gastrointestinal bleeding in critically ill children

AIM: To assess the frequency and the risk factors of stress-induced gastrointestinal (GI) bleeding in children admitted to a pediatric intensive care unit (PICU). METHODS: The medical records of children aged between 1 month and 15 years admitted to the PICU between January 2002 and December 2002 were reviewed. Demographic data, indications for PICU admission, principle diagnosis, and basic laboratory investigations were recorded. Previously described factors for stress ulcer bleeding (mechanical ventilation, sepsis, acute respiratory distress syndrome, renal insufficiency, coagulopathy, thrombocytopenia, and intracranial pathology) were used as independent variables in a multivariate analysis. RESULTS: One hundred and seventy of two hundred and five medical records were eligible for review. The most common indication for PICU admission was respiratory failure (48.8%). Twenty-five children received stress ulcer bleeding prophylaxis with ranitidine. The incidence of stress ulcer bleeding was 43.5%, in which 5.3% were clinically significant bleeding. Only mechanical ventilation and thrombocytopenia were significantly associated with stress ulcer bleeding using the univariate analysis. The odds ratio and 95% confidence intervals were 5.13 (1.86-14.12) and 2.26 (1.07-4.74), respectively. However, the logistic regression analysis showed that mechanical ventilation was the only significant risk factor with the odds ratio of 14.1. CONCLUSION: The incidence of gastrointestinal bleeding was high in critically ill children. Mechanical ventilation was an important risk factor for gastrointestinal bleeding.     

Stress ulcer prophylaxis in critically ill patients: a randomized controlled trial

BACKGROUND/AIMS: Critically ill patients especially who require mechanical ventilation or have coagulopathy are at increased risk for stress-related gastrointestinal hemorrhage. There are conflicting data on the efficacy and complication rates of various prophylactic regimens. METHODOLOGY: Our single-center randomized, placebo-controlled study included 287 patients with high risk for stress-related upper gastrointestinal hemorrhage (>48 h mechanical ventilation, coagulopathy). We compared 3 prophylactic regimens (proton pump inhibitor--omeprazole 40 mg i.v. once daily, n=72; H2 antagonists--famotidine 40 mg twice a day, n=71; and sucralfate 1 g every 6 hours, n=69) with placebo (n=75) in patients with trauma or after major surgery. RESULTS: Of 287 assessable patients, clinically significant stress-related upper gastrointestinal bleeding was observed in 1%, 3%, 4%, and 1% of patients assigned to receive omeprazole, famotidine, sucralfate, and placebo, respectively (p>0.28). Bleeding developed significantly more often in patients with coagulopathy compared with the others (10% vs. 2%; p=0.006). The gastric pH (p>0.001) and gastric colonization (p<0.05) was significantly higher in the patients who received pH increasing substances when compared with the other 2 groups. Nosocomial pneumonia occurred in 11% of patients receiving omeprazole, in 10% of famotidine patients, in 9% of sucralfate patients and in 7% of controls (p>0.34). No statistically significant differences were found for days on ventilator, length of ICU stay, or mortality among all the 4 groups. CONCLUSIONS: We could not show that omeprazole, famotidine, or sucralfate prophylaxis can affect already very low incidence of clinically important stress-related bleeding in high-risk surgical intensive care unit patients. Furthermore, our data suggested that especially gastric pH increasing medication could increase the risk for nosocomial pneumonia. Routine prophylaxis for stress-related bleeding even in high-risk patients seems not to be justified.     

Precedents for meaningful recovery during treatment in a medical intensive care unit. Outcome in patients with hematologic malignancy

The medical records of 77 patients with hematologic malignancy who were admitted to a medical intensive care unit over a 21-month period were reviewed. The overall hospital mortality rate was 80 percent. Sixteen patients (21 percent) were discharged from the intensive care unit but eventually died in the hospital. The cause of death was the result of a new problem in only three of these 16 patients. Hypotension (shock) and acute respiratory failure were the reasons prompting admission to the intensive care unit in 75 percent, but death in the intensive care unit was almost always the result of intractable hypotension rather than refractory hypoxemia. Only four of 52 patients who required mechanical ventilation left the hospital. In all four, the duration of ventilatory support was less than five days and the cause of respiratory failure was noninfectious in nature. Factors such as congestive heart failure, leukopenia, and abnormalities in mental status modified the hospital course, but did not alter outcome once prolonged mechanical ventilation became necessary. The data suggest that once acute respiratory failure develops in patients with lymphoma or leukemia, presumably as a result of infection, and mechanical ventilation for more than a relatively brief period is required, the prognosis is uniformly grim. Decisions to limit aggressive therapies is subsets of intensive care patients such as these should be aided by data that show a lack of precedent for meaningful recovery.     

Gastrointestinale Blutungen bei Intensivpatienten

Gastrointestinal bleeding is a dreaded complication in intensive care unit (ICU) patients and is associated with increased morbidity and mortality. The main risk factors for clinically important bleedings are (1) mechanical ventilation >48 h and (2) coagulopathy (PTT >2 times the upper limit of normal, INR >1.5, thrombocyte count <50000/µl). H2-receptor antagonists and proton pump inhibitors reduce the frequency of clinically important bleeding in patients at risk. These drugs are frequently used, although there is no evidence that mortality and/or the length of hospital stay are reduced. There is no difference in the strategies to treat bleeding episodes in ICU and non-ICU patients. ICU patients who suffer from liver disorders are at high risk of death when bleeding. Future studies have to elucidate whether specialized screening programs are needed.     

Stress-related mucosal disease: Incidence of bleeding and the role of omeprazole in its prophylaxis

BackgroundUpper gastrointestinal bleeding is the severe complication of stress-related mucosal disease in hospitalized patients. In intensive care units (ICU), risk factors are well defined and only mechanical ventilation and coagulopathy proved to be relevant for significant bleeding. On the contrary, in non-ICU settings there is no consensus about this issue. Nevertheless, omeprazole is still widely used in prophylaxis of bleeding. The objective of our study was to evaluate the relevance of stress-related mucosal disease bleeding in patients admitted to an internal medicine ward, and the role of omeprazole in its prophylaxis.MethodsWe conducted a retrospective study in which we analysed consecutive patients who were admitted to our ward over a year. We recorded demographic characteristics of the patients, potential risk factors for stress-related mucosal disease (clinical data, laboratory, and medication), administration of prophylactic omeprazole, and total cost of this prophylaxis. Patients with active gastrointestinal bleeding on the admission were excluded. We recorded every upper gastrointestinal bleeding event with clinical relevance.ResultsFive hundred and thirty-five patients, mean age 70 years, mean length of stay 9.6 ± 7.7 days; 140 (26.2%) patients were treated with 40 mg of omeprazole intravenously, 193 (36.1%) with 20 mg of omeprazole orally, and 202 (37.8%) patients had no prophylaxis. There was only one episode (0.2%) of clinically relevant bleeding.ConclusionIn patients admitted to an internal medicine ward, incidence of upper gastrointestinal bleeding as a complication of stress-related mucosal disease is low. We found that there is no advantage in prophylaxis with omeprazole.     

Impact of intensive insulin therapy on neuromuscular complications and ventilator dependency in the medical intensive care unit

RATIONALE: Critical illness polyneuropathy/myopathy causes limb and respiratory muscle weakness, prolongs mechanical ventilation, and extends hospitalization of intensive care patients. Besides controlling risk factors, no specific prevention or treatment exists. Recently, intensive insulin therapy prevented critical illness polyneuropathy in a surgical intensive care unit. OBJECTIVES: To investigate the impact of intensive insulin therapy on polyneuropathy/myopathy and treatment with prolonged mechanical ventilation in medical patients in the intensive care unit for at least 7 days. METHODS: This was a prospectively planned subanalysis of a randomized controlled trial evaluating the effect of intensive insulin versus conventional therapy on morbidity and mortality in critically ill medical patients. All patients who were still in intensive care on Day 7 were screened weekly by electroneuromyography. The effect of intensive insulin therapy on critical illness polyneuropathy/myopathy and the relationship with duration of mechanical ventilation were assessed. MEASUREMENTS AND MAIN RESULTS: Independent of risk factors, intensive insulin therapy reduced incidence of critical illness polyneuropathy/myopathy (107/212 [50.5%] to 81/208 [38.9%], p = 0.02). Treatment with prolonged (> or = 14 d) mechanical ventilation was reduced from 99 of 212 (46.7%) to 72 of 208 (34.6%) (p = 0.01). This was statistically only partially explained by prevention of critical illness polyneuropathy/myopathy. CONCLUSION: In a subset of medical patients in the intensive care unit for at least 7 days, enrolled in a randomized controlled trial of intensive insulin therapy, those assigned to intensive insulin therapy had a reduced incidence of critical illness polyneuropathy/myopathy and were treated with prolonged mechanical ventilation less frequently.     

Outcomes of intensive care for patients with human immunodeficiency virus infection

BACKGROUND: Intensive care for patients with human immunodeficiency virus is common, costly, and associated with high morbidity. Accurate and up-to-date outcome and prognostic data are needed to effectively counsel patients and to make difficult decisions regarding admission to the intensive care unit. METHODS: We reviewed the medical charts of 394 adults infected with human immunodeficiency virus who received intensive care at San Francisco General Hospital, San Francisco, Calif, from 1992 to 1995, and we performed a multivariate analysis to learn which factors were predictive of poor outcomes. RESULTS: Respiratory failure (47%), sepsis (12%), and neurologic disease (11%) were the most common indications for admission to the intensive care unit. Overall, 63% of the patients survived hospitalization; survival rates were 27%, 18%, 13%, and 11% at 1, 2, 3, and 4 years, respectively. Independent predictors of hospital mortality were low serum albumin level, Acute Physiology Score, mechanical ventilation, and a diagnosis of Pneumocystis carinii pneumonia during admission to the intensive care unit. Low CD4+ cell count, low serum albumin level, and mechanical ventilation predicted poor long-term survival. Of the 121 patients who had a CD4+ cell count less than 50 cells/microL (0.05x10(9)/L) and a serum albumin level less than 25 g/L and required mechanical ventilation, 7% survived for 2.5 years or more after hospital discharge. CONCLUSIONS: In this series, which is the largest to date of patients admitted to the intensive care unit with human immunodeficiency virus infection, we found that long-term survival rates were low. However, even among patients who had multiple risk factors for mortality, a substantial minority survived, with a few patients achieving long-term survival.     

Characteristics and outcome of patients with active pulmonary tuberculosis requiring intensive care.

Severe tuberculosis (TB) requiring intensive care unit (ICU) care is rare but commonly known to be of markedly bad prognosis. The present study aimed to describe this condition and to determine the mortality rate and risk factors associated with mortality. Patients with confirmed TB admitted to ICU between 1990 and 2001 were retrospectively identified and enrolled. Clinical, radiological and bacteriological data at admission and during hospital stay were recorded. A multivariate analysis was performed to identify the predictive factors for mortality. A total of 58 TB patients (12 females, mean age 48 yrs) admitted to ICU were included. Mean Acute Physiology and Chronic Health Evaluation (APACHE) II score at admission was 13.1+/-5.6 and 22 of 58 (37.9%) patients required mechanical ventilation. The in-hospital mortality was 15 of 58 (25.9%); 13 (22.4%) patients died in the ICU. The mean survival of patients who died was 53.6 days (range 1-229), with 50% of the patients dying within the first 32 days. The factors independently associated with mortality were: acute renal failure, need for mechanical ventilation, chronic pancreatitis, sepsis, acute respiratory distress syndrome, and nosocomial pneumonia. These data indicate a high mortality of patients with tuberculosis requiring intensive care unit care and identifies new independently associated risk factors.     

Prognostic factors for intensive care unit admission, intensive care outcome, and post-intensive care survival in patients with de novo acute myeloid leukemia: a single center experience

Background

Acute myeloid leukemia is a life-threatening disease associated with high mortality rates. A substantial number of patients require intensive care. This investigation analyzes risk factors predicting admission to the intensive care unit in patients with acute myeloid leukemia eligible for induction chemotherapy, the outcome of these patients, and prognostic factors predicting their survival.

Design and Methods

A total of 406 consecutive patients with de novo acute myeloid leukemia (15–89 years) were analyzed retrospectively. Markers recorded at the time of diagnosis included karyotype, fibrinogen, C-reactive protein, and Charlson comorbidity index. In patients requiring critical care, the value of the Simplified Acute Physiology Score II, the need for mechanical ventilation, and vasopressor support were recorded at the time of intensive care unit admission. The independent prognostic relevance of the parameters was tested by multivariate analysis.

Results

Sixty-two patients (15.3%) required intensive care, primarily due to respiratory failure (50.0%) or life-threatening bleeding (22.6%). Independent risk factors predicting intensive care unit admission were lower fibrinogen concentration, the presence of an infection, and comorbidity. The survival rate was 45%, with the Simplified Acute Physiology Score II being the only independent prognostic parameter (P<0.05). Survival was inferior in intensive care patients compared to patients not admitted to an intensive care unit. However, no difference between intensive care and non-intensive care patients was found concerning continuous complete remission at 6 years or survival at 6 years in patients who survived the first 30 days after diagnosis (non-intensive care patients: 28%; intensive care patients: 20%, P>0.05).

Conclusions

Ongoing infections, low fibrinogen and comorbidity are predictive for intensive care unit admission in acute myeloid leukemia. Although admission was a risk factor for survival, continuous complete remission and survival of patients alive at day 30 were similar in patients who were admitted or not admitted to an intensive care unit.     

Discharge decision-making in a medical intensive care unit. Identifying patients at high risk of unexpected death or unit readmission

In an attempt to identify clinical variables associated with unexpected death or unit readmission following discharge from a medical intensive care unit (MICU), 300 consecutive patients admitted to a MICU were prospectively identified and followed through their hospital stay. Of the 229 patients at risk, 37 (16 percent) experienced one or more unexpected unit readmissions (n = 30) or death (n = 7). In comparison to the patients without such complications (n = 192), these 37 patients differed with respect to age, diagnosis, and severity of illness on admission. In addition, these patients were sicker on initial unit discharge as manifested by higher heart and respiratory rates and lower hematocrit values. On multivariate analysis, age, acute physiology score on admission, and a diagnosis of upper gastrointestinal bleeding were independent predictors of unexpected outcome. It is concluded that patients at high risk for unit readmission or unexpected death are distinguished from other MICU survivors on several clinical parameters. Whether such information can be useful in individual discharge decisions is uncertain and requires further investigation.     

Clinically significant gastrointestinal bleeding in critically ill patients in an era of prophylaxis

OBJECTIVE: Clinical studies examining stress-related gastrointestinal bleeding in critically ill patients vary in their clinical definitions and assessment of clinical significance. Although there is evidence that routine prophylaxis decreases stress-related gastrointestinal bleeding, recent studies indicate a decreasing incidence, independent of the use of prophylactic medications. The purpose of this study was to determine the incidence of and risk factors for clinically significant, endoscopically proven gastrointestinal bleeding in critically ill patients. METHODS: A database (prospectively collected data) of 8338 patients admitted to the surgical and medical intensive care units at major tertiary care center from July 1988 to April 1995 was examined. All patients with significant upper gastrointestinal bleeding as defined by a drop in hemoglobin of >20 g/L and endoscopic evidence of an upper GI tract source were identified. Risk factors for GI bleeding from stress ulceration were compared in bleeding and nonbleeding patients. A case-control study analyzing risk factors for bleeding in the abdominal aortic aneurysm subgroup was performed. RESULTS: After exclusion criteria, 12/7231 (0.17%) patients had clinically significant, endoscopically proven bleeding. Significant risk factors included age, septic shock, abdominal aortic aneurysm repair, and nutritional support. Intensive care unit stay was prolonged in patients with stress-related bleeding. There was no difference in incidence of hypotension, clamp time, APACHE score, or operating room time in patients with abdominal aortic aneurysm repair as compared with controls. CONCLUSIONS: In an intensive care unit where stress prophylaxis is widely used, clinically important gastrointestinal bleeding is uncommon. Further study is needed to define the optimal prophylaxis regimen and the role for its selective use in high-risk patients.     

Hospitalized community-acquired pneumonia in the elderly: age- and sex-related patterns of care and outcome in the United States

Community-acquired pneumonia (CAP) is a frequent cause of hospital admission and death among elderly patients, but there is little information on age- and sex-specific incidence, patterns of care (intensive care unit admission and mechanical ventilation), resource use (length of stay and hospital costs), and outcome (mortality). We conducted an observational cohort study of all Medicare recipients, aged 65 years or older, hospitalized in nonfederal U.S. hospitals in 1997, who met ICD-9-CM-based criteria for CAP. We identified 623,718 hospital admissions for CAP (18.3 per 1,000 population > or = 65 years), of which 26,476 (4.3%) were from nursing homes and of which 66,045 (10.6%) died. The incidence rose five-fold and mortality doubled as age increased from 65-69 to older than 90 years. Men had a higher mortality, both unadjusted (odds ratio [OR]: 1.21 [95% CI: 1.19-1.23]) and adjusted for age, location before admission, underlying comorbidity, and microbiologic etiology (OR: 1.15 [95% CI: 1.13-1.17]). Mean hospital length of stay and costs per hospital admission were 7.6 days and $6,949. For those admitted to the intensive care unit (22.4%) and for those receiving mechanical ventilation (7.2%), mean length of stay and costs were 11.3 days and $14,294, and 15.7 days and $23,961, respectively. Overall hospital costs were $4.4 billion (6.3% of the expenditure in the elderly for acute hospital care), of which $2.1 billion was incurred by cases managed in intensive care units. We conclude that in the hospitalized elderly, CAP is a common and frequently fatal disease that often requires intensive care unit admission and mechanical ventilation and consumes considerable health care resources. The sex differences are of concern and require further investigation.     

Ineffectiveness of routine abdominal radiography in patients with gastrointestinal hemorrhage admitted to an intensive care unit

GOALS: To determine the utility of plain abdominal radiography in the initial evaluation of acute gastrointestinal (GI) hemorrhage in a medical intensive care unit. BACKGROUND: Plain abdominal radiographs are frequently used in the routine evaluation of patients with GI bleeding. The utility of these studies in the intensive care unit setting is unclear. STUDY: The study was a retrospective chart review of 71 adult subjects admitted to a medical intensive care unit with the diagnosis of GI bleeding. Subjects were excluded if they presented with peritoneal signs, received an abdominal CT scan in the 24 hours prior to admission, or were chronically treated with immunosuppressive medication. Subjects were divided into two cohorts based on whether or not they underwent plain abdominal radiography during the first hospital day. The primary study endpoints were hospital mortality, intensive care unit length of stay, and whether or not radiographic findings altered clinical management. RESULTS: Of the 71 patients admitted with a diagnosis of GI bleeding (mean age 65.8 +/- 14.5 years, 73.2% male), 56 (79%) had a plain abdominal radiograph performed. Subjects who had a plain film did not differ significantly from those who did not in age, gender, degree of anemia, degree of coagulopathy, or in severity of illness as measured by Acute Physiology and Chronic Health Evaluation (APACHE II) score. There was no statistically significant difference in hospital mortality or intensive care unit length of stay between patients who received plain films and those who did not. In no subject (0%; 95% confidence interval, 0%-5.4%) did abdominal radiography reveal an abnormality that altered clinical management. CONCLUSIONS: Based on our observations, plain films of the abdomen do not appear to alter clinical outcomes or management decisions for patients with GI bleeding and normal abdominal examinations who are admitted to the intensive care unit.     

Alcohol use disorders increase the risk for mechanical ventilation in medical patients

BACKGROUND: Annually, more than 300,000 patients receive mechanical ventilation in an intensive care unit in the United States. The hospital mortality for ventilated patients may approach 50%, depending on the primary diagnosis. In trauma and surgical patients, a diagnosis of alcohol use disorder (AUD) is common and is associated with a prolonged duration of mechanical ventilation. The objective of this study is to determine whether the presence of AUD and the development of alcohol withdrawal are associated with an increased use and duration of mechanical ventilation in patients with medical disorders that commonly require intensive care unit admission. METHODS: We performed a retrospective cohort study using the Nationwide Inpatient Sample, a large all-payer inpatient database representing approximately 1,000 hospitals. For the years 2002 to 2003, adult patients with 1 of the 6 most common diagnoses associated with medical intensive care unit admission were included in the study. Both univariate analysis and multivariable logistic regression were performed to determine whether AUD and alcohol withdrawal were independently associated with the use and duration of mechanical ventilation in these patients. RESULTS: There were a total 785,602 patients who fulfilled 1 of the 6 diagnoses, 26,577 (3.4%) had AUD, 3,967 (0.5%) had alcohol withdrawal, and 65,071 (8.3%) underwent mechanical ventilation (53% <96 hours, 47%> or =96 hours). Independent of the medical diagnosis, AUD was associated with an increased risk of requiring mechanical ventilation (13.7 vs 8.1%, odds ratio=1.49, 95% confidence interval [1.414; 1.574], p<0.0001) but was not associated with a prolonged duration of mechanical ventilation. However, the presence of alcohol withdrawal was associated with a longer duration of mechanical ventilation (57 vs 47%> or =96 hours, odds ratio=1.48, 95% confidence interval [1.266; 1.724], p<0.0001). CONCLUSIONS: In patients with medical diagnoses associated with intensive care unit admission, AUD increases the risk for mechanical ventilation while the development of alcohol withdrawal is associated with a longer duration of mechanical ventilation.     

Nasal high flow therapy use in wards in patients with chronic obstructive pulmonary disease may spare ICU resources

Nasal high flow therapy has been previously studied for the management of acute hypoxic respiratory failure in patients with chronic obstructive pulmonary disease but the data regarding its use outside of the intensive care unit are sparse. We aimed to evaluate safety and efficacy of nasal high flow therapy outside of the intensive care unit in patients with acute hypoxic respiratory failure and known chronic obstructive pulmonary disease. We conducted a retrospective matched historic cohort study of adult patients with diagnosed chronic obstructive pulmonary disease presenting with acute hypoxic respiratory failure between December 2017 to June 2019, after the initiation of a new protocol, which allowed patients to be managed with nasal high flow therapy on the medical/surgical wards instead of transferring them to the ICU per prior standard of care. Nasal high flow therapy was initiated either in the emergency department or on the medical/surgical wards. Patients were matched with historical cohorts who were managed with prior standard of care based on age, body mass index, comorbidities, and home oxygen use. Primary outcome of interest was difference in rates of mechanical ventilation. Secondary outcomes included hospital length of stay, total number of days spent in the intensive care unit, and in‐hospital mortality. A total of 90 patients met study inclusion criteria and were matched to 90 historical control patients. Among the study group, 8% required mechanical ventilation versus 9% in the control group (p = 0.79). Hospital length of stay was 7 days in study group versus 6 days in control group (p = 0.02), and in‐hospital mortality was the same in both study and control groups at 12% (p = 0.99). Nineteen percent of study group patients required ICU level of care at any time during the admission compared with 49% of control group (p < 0.001). Nasal high flow therapy use in patients with acute hypoxic respiratory failure and underlying chronic obstructive pulmonary disease outside of the intensive care unit may spare ICU resources and cost without delay in definitive care such as mechanical ventilation.     

Risk factors for mortality in severe upper gastrointestinal bleeding

Background and aims Factors related to mortality after upper gastrointestinal (GI) bleeding may differ in importance in high- and low-risk populations. This retrospective study was undertaken to define risk factors of mortality in patients needing endoscopy for upper gastrointestinal bleeding at a tertiary care centre.Patients/methods Three hundred and sixty-two patients with upper gastrointestinal bleeding were identified from endoscopy charts. Patients characteristics, bleeding parameters, clinical presentation, pre-existing medication and laboratory data were retrieved from hospital charts and patients who survived and those who died in hospital were compared.Results/findings The mean Rockall score was 6.6±1.3 with 92.5% of patients belonging to a Rockall high-risk group. In hospital, mortality was 26.5%, with 6.4% of patients dying as a direct consequence of bleeding. Variceal bleeding was associated with a high risk of recurrent bleeding and death. Renal disease, liver disease, coagulopathy and immunosuppression were more frequently found in non-survivors than in survivors. Accordingly, serological tests of renal or liver function and coagulation were more disturbed in non-survivors. On average, heart rate was higher, and blood pressure and haemoglobin levels lower in non-survivors. Heparin, glucocorticoids, and anti-ulcer drugs were more frequently used in patients dying in hospital. By logistic regression analysis, in-patient status at the time of bleeding, renal disease and coagulopathy, as well as glucocorticoid use, were risk factors for hospital mortality.Interpretation/conclusion In tertiary care, a high mortality rate is observed in upper GI bleeding. Teams involved in treating such patients should be aware of the setting in which treatment is performed and its related risk factors.     

The clinical impact of bleeding during oral anticoagulant therapy

Although the risk for bleeding during long-term warfarin therapy is established, little is known about the clinical impact following warfarin-associated bleeding and the management of anticoagulant resumption after a bleed. We performed a retrospective chart review of patients who suffered a warfarin-associated bleed that required hospitalization or that occurred during hospitalization. We determined the proportion of patients who required a blood product transfusion, a surgical or other invasive procedure or admission to an intensive care unit, and the duration of hospitalization. We also determined the case-fatality rate of bleeding and described post-bleed resumption of anticoagulation. We studied 142 patients (70 women) hospitalized with warfarin-associated bleeding with a mean age of 73 years. The most prevalent sites of bleeding were the gastrointestinal tract (40.8%) and urinary tract (14.1%). Of all bleeding episodes, 72 (50.1%) were classified as major bleeds. There were 66 (46.4%) patients who required either endoscopy, surgery or admission to an intensive care unit, and the mean duration of hospitalization was 23 days. The case fatality rate of major bleeding was 9.5%. Among patients in whom warfarin was restarted, 8.3% suffered recurrent bleeding. Warfarin-associated bleeding appears to confer considerable morbidity related to transfusion and hospitalization, approximately 1 in 10 major bleeds are fatal, and 1 in 12 patients will re-bleeding after warfarin resumption.     

Profilaxis para sangrado por ulceras de estrés en la unidad de cuidados intensivos

BackgroundThe critically ill patient can develop gastric erosions and, on occasion, stress ulcers with severe gastrointestinal bleeding that can be fatal.AimsThe purpose of this review was to provide current information on the pathophysiology, risk factors, and prophylaxis of digestive tract bleeding from stress ulcers in the intensive care unit.MethodsWe identified articles through a PubMed search, covering the years 1970 to 2013. The most relevant articles were selected using the search phrases “stress ulcer”, “stress ulcer bleeding prophylaxis”, and “stress-related mucosal bleeding” in combination with “intensive care unit”.ResultsThe incidence of clinically significant bleeding has decreased dramatically since 1980. The most important risk factors are respiratory failure and coagulopathy. Proton pump inhibitors (PPIs) or H2 receptor antagonists (H2RAs) are used in stress ulcer bleeding prophylaxis. Both drugs have been shown to be superior to placebo in reducing the risk for gastrointestinal bleeding and PPIs are at least as effective as H2RAs. Early enteral feeding has been shown to reduce the risk for stress ulcer bleeding, albeit in retrospective studies.ConclusionsAdmittance to the intensive care unit in itself does not justify prophylaxis. PPIs are at least as effective as H2RAs. We should individualize the treatment of each patient in the intensive care unit, determining risk and evaluating the need to begin prophylaxis.     

Gastrointestinal complications after transperitoneal abdominal aortic surgery

A major gastrointestinal complication after transperitoneal aortic surgery, though unusual, may be disastrous. We determined retrospectively the risk factors, associated events, and outcomes of gastrointestinal complications that developed after transperitoneal aortic revascularization to treat aneurysmal or occlusive disease over a 10-year period. Among 750 patients reviewed, gastrointestinal complications developed postoperatively in 65 of them (8.6%), including paralytic ileus in 35 patients, gastrointestinal bleeding and mechanical ileus in 6 patients each, colonic necrosis in 2, ischemic colitis and diarrhea in 10, acute cholecystitis in 2, ascites in 1, as well as aortoduodenal fistula, which developed about 2 months postoperatively in 3 patients. Five of the patients died of multiorgan failure. Mean stay in the intensive care unit was 3 days, and hospital stay ranged from 15 to 60 days. No risk factors were identified for the occurrence of gastrointestinal complications. These results show that gastrointestinal complications after transperitoneal aortic surgery prolong hospital stay and may have serious consequences.