"Risk Factors for Gastrointestinal Bleeding in Critically Ill Patients". Canadian Medical Association Journal. YEAR MISSING. (VOLUME ISSUE MISSING):PAGE NUMBERS MISSING.

Clinical Question

In critically ill patients, what are the risk factors for stress ulceration leading to clinically important gastrointestinal bleeding, and can prophylaxis against stress ulcers be selectively administered?

Bottom Line

Critically ill patients have a low incidence of clinically important gastrointestinal bleeding; therefore, prophylaxis against stress ulcers can be safely withheld unless patients have coagulopathy or require mechanical ventilation.

Major Points

The necessity of stress ulcer prophylaxis in all critically ill patients has been debated due to its associated costs and potential side effects. This prospective cohort study identified two strong independent risk factors for stress ulceration: respiratory failure and coagulopathy. The study concluded that prophylaxis can be safely withheld from critically ill patients unless they display these indicated risk factors.

Guidelines

While current guidelines were not addressed in the study, implication from the study suggests critically ill patients without the two identified risk factors may not require routine stress ulcer prophylaxis.

Design

Prospective multicenter cohort study conducted in four university-affiliated medical-surgical intensive care units.

Population

A total of 2252 critically ill patients aged over 16 years.

Inclusion Criteria
- Hospitalized in intensive care units
- Patients older than 16 years

Exclusion Criteria
- Upper gastrointestinal bleeding within 48 hours before or 24 hours after admission
- Previous total gastrectomy
- Facial trauma or epistaxis
- Brain death
- Hopeless prognosis
- Died or discharged within 24 hours after admission

Interventions

Critically ill patients evaluated for risk factors for gastrointestinal bleeding and occurrence of clinically important bleeding.

Outcomes

Primary Outcomes:
- Clinically important gastrointestinal bleeding defined as overt bleeding associated with hemodynamic compromise or the need for blood transfusion.

Secondary Outcomes:
- The impact of prophylaxis on the incidence of bleeding, incidence of stress ulceration, and risk factors contributing to gastrointestinal bleeding.

Criticisms

- The study encouraged withholding prophylaxis in select patients, which may have introduced bias.
- The lack of randomization may have led to confounding.
- Resource limitations that led to the enrollment of subgroups of patients on a random basis and exclusion on weekends.

Funding

Supported by the Ontario Ministry of Health.

Further Reading

Full report details and further discussions on the study can be found in the Canadian Medical Association Journal (Volume and Issue Missing, Year Missing, Page Numbers Missing).