Risk Factors for Gastrointestinal Bleeding in Critically Ill Patients
Deborah J. Cook, Hugh D. Fuller, Gordon H. Guyatt, John C. Marshall, David Leasa, Richard Hall, Timothy L. Winton, Frank Rutledge, Thomas Todd, Peter Roy, Jacques Lacroix, Lauren Griffith, Andrew Willan, for The Canadian Critical Care Trials Group
Background The efficacy of prophylaxis against stress ulcersin preventing gastrointestinal bleeding in critically ill patientshas led to its widespread use. The side effects and cost ofprophylaxis, however, necessitate targeting preventive therapyto those patients most likely to benefit.
Methods We conducted a prospective multicenter cohort studyin which we evaluated potential risk factors for stress ulcerationin patients admitted to intensive care units and documentedthe occurrence of clinically important gastrointestinal bleeding(defined as overt bleeding in association with hemodynamic compromiseor the need for blood transfusion).
Results Of 2252 patients, 33 (1.5 percent; 95 percent confidenceinterval, 1.0 to 2.1 percent) had clinically important bleeding.Two strong independent risk factors for bleeding were identified:respiratory failure (odds ratio, 15.6) and coagulopathy (oddsratio, 4.3). Of 847 patients who had one or both of these riskfactors, 31 (3.7 percent; 95 percent confidence interval, 2.5to 5.2 percent) had clinically important bleeding. Of 1405 patientswithout these risk factors, 2 (0.1 percent; 95 percent confidenceinterval, 0.02 to 0.5 percent) had clinically important bleeding.The mortality rate was 48.5 percent in the group with bleedingand 9.1 percent in the group without bleeding (P<0.001).
Conclusions Few critically ill patients have clinically importantgastrointestinal bleeding, and therefore prophylaxis againststress ulcers can be safely withheld from critically ill patientsunless they have coagulopathy or require mechanical ventilation.
Source Information
From the Faculty of Health Sciences, McMaster University, Hamilton, Ont. (D.J.C., H.D.F., G.H.G., L.G., A.W.); Toronto General Hospital and the University of Toronto, Toronto (J.C.M., T.L.W., T.J.R.T.); University Hospital and the University of Western Ontario, London, Ont. (D.L.); Victoria General Hospital and Dalhousie University, Halifax, N.S. (F.R.); Victoria General Hospital and the University of Western Ontario, London, Ont. (R.H., P.R.); and Hopital Ste.-Justine and the Universite de Montreal, Montreal (J.L.) -- all in Canada. In addition to the authors, the participants in the Canadian Critical Care Trials Group were as follows: Project Group -- H. Fuller and P. Powles, Hamilton, Ont., J. Lacroix, Montreal, J. Marshall, Toronto, T. Noseworthy, Edmonton, Alta., and L. Oppenheimer, Winnipeg, Man.; Outcome Review Committee -- D. Cook, H. Fuller, J. Hewson, J. Lang, H. Lee, and P. Powles, Hamilton, Ont., B. Guslits, Detroit, M. Heule and T. Noseworthy, Edmonton, Alta., J. Lacroix, Montreal, and J. Marshall and T. Todd, Toronto; Data Monitoring -- P. Powles, Hamilton, Ont.
Address reprint requests to Dr. Cook at the Department of Medicine, Division of Critical Care, St. Joseph's Hospital, 50 Charlton Ave. E., Hamilton, ON L8N 4A6, Canada.
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