RISK FACTORS FOR GASTROINTESTINAL BLEEDING IN CRITICALLY ILL PATIENTS

OVMC LANDMARK TRIAL SERIES

COOK DJ, ET AL. "RISK FACTORS FOR GASTROINTESTINAL BLEEDING IN CRITICALLY ILL PATIENTS". THE NEW ENGLAND JOURNAL

OF MEDICINE. 1994. 330(6):337-381.

BACKGROUND

Before this landmark trial, use of PPI for stress ulcer prophylaxis is widespread in both ICU and non-ICU patients, despite lack of indication

Patients started on PPI get continued on this medication upon discharge

SUBJECT

In critically ill patients, what is the incidence of significant GI bleed and what are the risk factors that require GI prophylaxis?

DESIGN

Trial Design: Multicenter, prospective, observational study Location: Four academic ICUs Mean follow up: Not identified Subject=2,252 Primary outcomes:

Overt bleeding OR clinically important bleeding Overt bleeding (hematemesis, gross blood or “coffee grounds” material in a

nasogastric aspirate, hematochezia, or melena) Clinically important bleeding is defined as sBP drop 20 mmHg or HR increase

20 bpm; Hgb drop 2g Of 2252 patients, 33 (1.5 percent; 95 percent confidence interval, 1.0 to 2.1

percent) had clinically important bleeding.

INTERVENTION

WITHOLD GI prophylaxis in all patients EXCEPT: Head injury Burns over >30% BSA Organ transplant recipients Diagnosis of gastritis in the previous 6 weeks Upper GI bleeding three to six weeks before admission

Patients were followed for bleeding Prophylaxis options included H2 antagonists, antacids, sucralfate, prostaglandin

analogues, and omeprazole

CRITICISMS

The study did not clearly define who was considered a critically ill patient (eg included CV surgical patients who are at low risk for GI complications)

Low rate of sepsis, cardiovascular, or respiratory disease as reason for ICU admissions

Coagulopathy defined by elevation in fibrin-split products may better define the condition than alterations in PT/aPTT as warfarin and heparin do not increase risk for GI bleeding

BOTTOM LINE

Greatest risk factors for GI bleeding in ICU patients are coagulopathy and mechanical ventilation >48hours

Incidence of clinically important bleeding was less than 2% among >2000 patients in this study

Identifying risk of GI bleeding allows more selective use of PPX against stress ulcers, thus avoiding the unnecessary exposure of patients to side effects of PPX

GI PPX

Major risk (need 1)• Coagulopathy (INR > 1.5, Plt <

50K, or PTT > 2x normal)• Mechanical ventilation > 48hrs• GI ulceration or bleeding within the

past year• Traumatic brain or spinal cord injury• Severe burn (>35% of the body

surface area)

Minor Risk (need >2)• Sepsis• ICU stay > 1 week• Occult GI bleeding > 6 days• High dose glucocorticoid therapy

(>250mg hydrocortisone or equiv.)

• Enteral feeding (on case basis)

GI PROPHYLAXIS ON WARDS

NOOONNNNEEEE!!!

DISCUSSION QUESTION

What are the 2 most important risk factors for GI bleeding in ICU?

Name 3 other risk factors for GI bleeding in ICU.

What type of study is this?

What is one criticism of this study?

CLINICAL APPLICATION: GI PPX OR NOT

75yo w/ DM2, HTN, and ESRD on HD p/w left hip fracture, who was kept NPO for the past 3 days due to delaying in surgery schedule

16 yo male w/ DM1 admitted to ICU for DKA secondary to non-compliance

68 yo female w/ DMI2, HLD, and COPD p/w COPD exacerbation caused by community acquired pneumonia requiring 5 day of intubation.

36yo female w/ HIV and found to have CBS lymphoma started on low dose dexamethasone and palliative brain radiation.

59yo active drinker w/ hep C cirrhosis admitted for monitoring of withdrawal symptoms. INR 2.5, platelets 90, albumin 2.8, PTT normal ,and bilirubin 2.

REFERENCES

Cook DJ, et al. "Risk factors for gastrointestinal bleeding in critically ill patients". The New England Journal of Medicine. 1994. 330(6):337-381.

Brain, L. P. (n.d.). GI bleeding in ICU patients. https://www.wikijournalclub.org/wiki/GI_bleeding_in_ICU_patients