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Significant Upper Gi – Bleeding In Critically Ill
Patients
Manucherhr Khoshbaten
Associated professor of gastroenterology department
Liver and gastroenterology research center
Imam university
hospital
Iran
Haleh Farzin
General practitioner
Molaalmovaehdin General
clinic
Iran
Ebrahim Fattahi
Associated professor of gastroenterology department
Liver and gastroenterology research center
Imam university
hospital
Iran
Masoud Entezarie Asl
Assistant of anesthesiology department
Ardabil
university of medical sciences
Iran
Citation:
Manucherhr Khoshbaten, Haleh Farzin, Ebrahim Fattahi, Masoud
Entezarie Asl: Significant Upper Gi – Bleeding In Critically Ill
Patients. The Internet Journal of Gastroenterology. 2007. Volume
5 Number 2.
Table of Contents
Abstract
Introduction
Methods
Results
Discussion
References
AbstractBackground: To evaluate risk
factors for clinically important upper gastrointestinal bleeding
in critically ill patients requiring mechanical ventilation.
Methods: In this prospective study, we determined the
presence of clinically important gastrointestinal bleeding,
evaluated relevant clinical, laboratory, and diagnostic criteria
at four University-affiliated intensive care units in Tabriz,
Iran. A total of 300 critically ill ICU patients were ventilated
for at least 48 hours. Demographic data included patient
characteristics and multiple organ dysfunction score. Each day in
the ICU, physiologic measurements including multiple organ
dysfunction score, feeding, and other drug variable were recorded.
Data were analyzed by t-test and mann Whitney test.
Results: The significant risk factors for upper gastro
intestinal bleeding were low platelet count, maximum serum
creatinin, maximum pulmonary component multiple organ dysfunction
score, maximum respiratory component multiple organ dysfunction
score, maximum cardiac component multiple organ dysfunction score.
Conclusions: In critically ill ventilated patients,
renal failure respiratory, cardiac dysfunction, and coagulopathy
disorder were associated with an increased risk significant
gastrointestinal bleeding whereas enteral nutrition and stress
ulcer prophylaxis with ranitidine decreased gastrointestinal
bleeding. |
Introduction
Critically ill patients who are require mechanical ventilation are at
increased risk for gastrointestinal bleeding from stress ulcer ( 1 ), and overt evidence of upper
gastrointestinal bleeding is not uncommon in critically ill patients ( 2 , 3 , 4 , 5 , 6 , 7 ). Although hemorrhage from stress ulceration
occurs in only 5-20% of patients in an ICU ( 8 ), there is evidence that routine prophylaxis
decreases stress related gastro intestinal bleeding ( 9 ). We undertook this retrospective study to
assess significant gastrointestinal bleeding in patients admitted to our
intensive care units and determine risk factors in patients with multi
organ dysfunction.
Methods
Consecutive 300 patients who were hospitalized at four
university-affiliated medical and surgical intensive care units and
needed ventilation for more than 48 hours, were considered for study.
Exclusion criteria were gastrointestinal bleeding in admission time,
life expectancy lower than 72 hours and history of gastrointestinal
surgery. Demographic data included patient characteristics, history and
physical exam, para clinic tests, nutrition, drugs, and prophylaxis.
Clinically important upper gastrointestinal bleeding were defined as:
spontaneous decreasing blood pressure> 20 mm hg at 24 hours after
admission , increasing pulse rate 20 beats / minute and orthostatic
blood pressure change , hemoglobin decreasing >= 2 gr/dl within 24
and need for blood transfusion within 24 hours after bleeding( 3 , 14 ). Multiple organ dysfunction score
assessment was defined as: respiratory system (defined Po2/Fio2
fraction> 300 = stage 0), cardiac system( pressure - adjusted heart
rate <=10 = stage 0, stage 1= 10.1 – 15, stage 2 = 15.1-20, stage 3 =
20.1-30, stage 4>30 ), renal system( serum creatinine (mg/dl),
stage0= 1, stage1=2.01-3.5, stage 3 = 3.51-5.00, stage4>5), hepatic
system (serum billirubin (mg/dl) , stage0<= 2, stage1=2.1-6, stage2=
6.1-12 , stage3 = 12.1-24, stage4>24), hematologic system (platelet
cell/ml3 , stage0= 120000 ,stage1=81-120, stage 2=51-80, stage3=21-50,
stage 4<=20), central nervous system( defined as Glasgow coma scale
score)( 10 , 11 ). Daily evaluation included significant
upper GI bleeding symptoms as hematemesis, bloody aspiration in
nasogastric tube, melena or hematochesis ,administration of heparin or
warfarin, glucocorticoids, aspirine or another non steroidal anti
inflammatory drugs , need for ventilation for at least 48 hours), using
of enteral feeding, using of stress ulcer prophylaxis.
We analyzed variables with the Coxs regression model, compared them
with students t-test and compared proportions with chi- square test.
Variables were significantly associated (P<0.05) with clinically
important bleeding.
Results
Of 300 patients admitted and studied in intensive care units (153
male, 147 female), 80 (26.7%) cases had clinically important
gastrointestinal bleeding (42 had melena and coffee ground aspiration in
nasogastric tube, 21 had only melena, 14 had melena and red aspiration,
3 had only red aspiration). 23.95 % had respiratory failure, 19.79 % had
CNS problems and 16.79 % had cardiovascular dysfunction, 12.27 % had
Sepsis.
Table 1: Risk factors in bleeder and non – bleeder
groups
The significant risk factors for upper gastro intestinal bleeding
were low platelet count, maximum serum creatinin, maximum pulmonary
component multiple organ dysfunction score, maximum respiratory
component multiple organ dysfunction score, maximum cardiac component
multiple organ dysfunction score. 42.25% of patients had coagulopathy
problem. Bleeding occurrence in 65% had been seen in the first 2 weeks
after admission. Non bleeder group (220) were younger than bleeder group
(80) but (55.7%) in non – bleeder group were female, had shorter stays
in the intensive unit care (7.5±5.6 vs 19.8± 18.5,P = 0.001) and had
lower MOD score(P=0.05). Significant differences were not seen between 2
groups about sex and age (P = 0.15).
Clinically important bleeding was associated with low platelet count
(CI 95% = 4.44, P= 0.03), maximum serum creatinine (CI 95% = 6.87, P =
0.004), maximum pulmonary component (CI 95% = 1.08 , P= 0.022), maximum
cardiac component (CI 95% = 1.05, P= 0.031), coagulopathy
(P=0.03).Patients with high risk factors had high risk for bleeding ,
i.e positive relationship was seen between increasing risk factors and
bleeding (P = 0.003).
Discussion
We found that clinically important bleeding was associated with an
increased risk, MODS score, length of ventilation, and length of
hospitalization. Admitting diagnosis, ventilation length, bleeding
status is important in our study. Other studies have estimated stress
ulcer associated bleeding increased risk of ventilation and ICU stay,
high morbidity and mortality rate. In our study, the incidence of
clinically important gastrointestinal bleeding was 26.7%, But in
Nithiwathanpong et al study ( 20 ) its incidence was 43.5%, in Deborah et al
( 1 ) was 1.7%, in another Deorah ( 3 ) study was 1.5%,and in Pimentel et al study
( 8 ) was 0.17%. Therefore , the clinically
important GI bleeding incidence vary in different studies but our result
showed that bleeding in critically patients is not rare. Virtually all
patients who are under the physiologic stress of an intensive care unit
(ICU) are vulnerable to stress-related mucosal damage and ulceration ( 12 ). Current clinical opinion and available
evidence suggests that the early appropriate referral of patients to ICU
can significantly reduce early, and possibly late, mortality in the
critically ill( 13 ). This common event has high mortality and
may be, prophylaxis can reduce risk factors and bleeding induced
mortality. The current overview demonstrates that prophylaxis decreases
clinically important bleeding (OR, 0.44; 95% CI, 0.22 to 0.88)( 21 ). Although the bleeding episodes stops
spontaneously in most of patients ( 15 ), we found that 46 pateints (57.5%) had
experienced stress ulcer bleeding episodes in first 6-10 days. Terdiman
et al study showed that clinically important gastrointestinal bleeding
occurred in 67 inpatients after a mean hospital length stay 14 ± 10 days
( 16 ), and Deborah et al observed the risk of
bleeding to increased, 75% of events occurred in the first 2 weeks of
ICU stay ( 19 ).Therefore, in different studies GI
bleeding occur after 2 weeks of ICU admission. 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 ( 14 ). In the Chaibou et al study, respiratory
failure and coagulopathy were complications that attributed with
gastrointestinal bleeding ( 17 ). A Canadian trial group found that risk
factors for upper gastrointestinal bleeding were low platelet count ,
maximum serum creatinin, maximum MOD score (maximum renal, hepatic,
pulmonary)( 18 ). Dysfunction of specific organs
(pulmonary, hepatic, renal) and overall multiple organ dysfunction were
associated with an increased risk of bleeding ( 19 ). Previously described factors for stress
ulcer bleeding (mechanical ventilation, sepsis, acute respiratory
distress syndrome, renal insufficiency, coagulopathy, thrombocytopenia,
and intracranial pathology) were similarly in our study ( 20 ).
The patients of the two treatment groups (each 16) were comparable
with respect to diseases precipitating acute respiratory failure and
risk factors of bleeding, e.g., renal failure, thrombopenia,
coagulopathy, and anticoagulant treatment ( 22 ). Laggner et al found that age, clinical
evidence of shock, hepatic dysfunction and hemoglobin less than 8.0 g/dl
(80 g/L) to be significant in prediction of risk of further
hemorrhage( 23 ) and, Supe et al study showed that
significant risk factors for upper gastro intestinal bleeding were low
platelet count, maximum serum creatinin, maximum pulmonary component
multiple organ dysfunction score, maximum respiratory component multiple
organ dysfunction score, maximum cardiac component multiple organ
dysfunction score. We have similar results compared to other studies.
In summary, in our population of 300 patients ventilated for > 48
hours, it could be shown that clinically important gastrointestinal
bleeding is associated with high MOD score, high duration of
ventilation, and high length of ICU stay. Likely, it seems that bleeding
can increase duration of above items.
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