Published on May 13, 2016
1. RISK FACTORS FOR GASTROINTESTINAL BLEEDING IN CRITICALLY ILL PATIENTS COOK DJ, ET AL. "RISK FACTORS FOR GASTROINTESTINAL BLEEDING IN CRITICALLY ILL PATIENTS". THE NEW ENGLAND JOURNAL OF MEDICINE. 1994. 330(6):337-381. SALT-E: OVMC LANDMARK TRIAL SERIES 2016
2. SUBJECT 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
3. SUBJECT In critically ill patients, what are the risk factors for developing gastrointestinal hemorrhage?
4. DESIGN Multicenter, prospective, observational study Enrollment: 1990-1991 Location: Four academic ICUs Mean follow up: Not identified Subject=2,252
5. INTERVENTION Attending physicians encouragedWITHOLD 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
6. OUTCOMES Primary outcomes: Clinically important Bleeding Of 2252 patients, 33 (1.5 percent; 95 percent confidence interval, 1.0 to 2.1 percent) had clinically important bleeding.
7. CRITICISMS Did not clearly define what comprised a critically ill patient and included many cardiovascular surgical patients -- a group at low risk for 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
8. BOTTOM LINE A simple rule predicts the risk of GI bleeding and allows more selective use of prophylaxis against stress ulcers, thus avoiding the unnecessary exposure of patients to potential adverse effects. The greatest risk factors for GI bleeding in critically ill patients are coagulopathy and mechanical ventilation >48hours.
9. THIS ARTICLE LED TO RECS FOR GI PPX • 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) Major risk (need at least 1) 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)
10. GI PROPHYLAXIS ONWARDS NOOONNNNEEEE!!!
11. 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?
12. 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.
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