Risk factors for clinically important upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group

Therapeutic intent of proton pump inhibitor prescription among elderly nonsteroidal anti-inflammatory drug users

BACKGROUND

Prescription of proton pump inhibitors (PPIs) has increased dramatically.

AIM

To assess therapeutic intent of PPI prescription among elderly veterans prescribed nonsteroidal anti-inflammatory drugs.

METHODS

Medical-record abstraction identified therapeutic intent of PPI prescription. An 'appropriate therapeutic intent' was defined as symptomatic gastro-oesophageal reflux disease or endoscopic oesophagitis, Zollinger-Ellison disease, dyspepsia, upper gastrointestinal event, Helicobacter pylori infection or nonsteroidal anti-inflammatory drug gastroprotection. Logistic regression predicted the outcome while adjusting for clinical characteristics.

RESULTS

Of 1491 patients [mean 73 years (s.d. 5.6), 73% white and 99.8% men], among those charts which did document a therapeutic indication, 88.8% were appropriate. Prior gastroscopy was predictive of an appropriate therapeutic intent (OR 2.7; 95% CI: 1.9-3.7). Prescription to patients who used VA pharmacy services only, to in-patients, or by a cardiologist or an otolaryngologist were less likely to be appropriate. Gastroprotection was poorly recognized as an indication for PPI prescription, except by rheumatologists (OR 46.7; 95% CI: 15.9-136.9), or among highly co-morbid patients (OR 1.8; 95% CI: 1.1-2.9). Among in-patients, 45% of PPI prescriptions were initiated for unknown or inappropriate reasons.

CONCLUSIONS

Type of provider predicts appropriate PPI use. In-patient prescription is associated with poor recognition of necessary gastroprotection and unknown therapeutic intent.

Analysis of clinical risk factors associated with the prognosis of severe multiple-trauma patients with acute lung injury

BACKGROUND

Several clinical risk factors have been reported to be associated with the prognosis of acute lung injury (ALI). However, these studies have included a general trauma patient population, without singling out the severely injured multiple-trauma patient population.

OBJECTIVES

To identify the potential risk factors that could affect the prognosis of ALI in multiple-trauma patients and investigate the prognostic effects of certain risk factors among different patient subpopulations.

METHODS

In this retrospective cohort study, severely injured multiple-trauma patients with early onset of ALI from several trauma centers were studied. Potential risk factors affecting the prognosis of ALI were examined by univariate and multivariate logistic analyses.

RESULTS

There were 609 multiple-trauma patients with ALI admitted to the emergency department and emergency intensive care unit during the study period. The nine risk factors that affected prognosis, as indicated by the unadjusted odds ratios with 95% confidence intervals, were the APACHE II (Acute Physiology and Chronic Health Evaluation II) score, duration of trauma, age, gastrointestinal hemorrhage, pulmonary contusion, disseminated intravascular coagulation (DIC), multiple blood transfusions in 6 h, Injury Severity Score (ISS), and aspiration of gastric contents. Specific risk factors also affected different patient subpopulations in different ways.

CONCLUSIONS

Patients older than 65 years and with multiple (> 10 units) blood transfusions in the early stage after multiple trauma were found to be independent risk factors associated with deterioration of ALI. The other factors studied, including pulmonary contusion, APACHE II score ≥ 20, ISS ≥ 16, gastrointestinal hemorrhage, and aspiration of gastric contents, may predict the unfavorable prognosis of ALI in the early stage of trauma, with their effects attenuating in the later stage. Duration of trauma ≥ 1 h and the presence of DIC may also indicate unfavorable prognosis during the entire treatment period.

Hospital-acquired pneumonia: pathophysiology, diagnosis, and treatment

Hospital-acquired pneumonia (HAP) is one of the most common causes of nosocomial infection, morbidity, and mortality in hospitalized patients. Many patient- and disease-specific factors contribute to the pathophysiology of HAP, particularly in the surgical population. Risk-factor modification and inpatient prevention strategies can have a significant impact on the incidence of HAP. While the best diagnostic strategy remains a subject of some debate, prompt and appropriate antimicrobial therapy in patients suspected of having HAP has been shown to significantly decrease mortality. Because the pathogens responsible for HAP are frequently more virulent and have greater resistance to commonly used antimicrobials than other pathogens, clinicians must have knowledge of the resistance patterns at their institutions to choose appropriate therapy.

Effects of different peep levels on mesenteric leukocyte-endothelial interactions in rats during mechanical ventilation

INTRODUCTION

Mechanical ventilation with positive end expiratory pressure (PEEP) improves oxygenation and treats acute pulmonary failure. However, increased intrathoracic pressure may cause regional blood flow alterations that may contribute to mesenteric ischemia and gastrointestinal failure. We investigated the effects of different PEEP levels on mesenteric leukocyte-endothelial interactions.

METHODS

Forty-four male Wistar rats were initially anesthetized (Pentobarbital I.P. 50 mg/kg) and randomly assigned to one of the following groups: 1) NAIVE (only anesthesia; n=9), 2) PEEP 0 (PEEP of 0 cmH2O, n=13), 3) PEEP 5 (PEEP of 5 cmH2O, n=12), and 4) PEEP 10 (PEEP of 10 cmH2O, n=13). Positive end expiratory pressure groups were tracheostomized and mechanically ventilated with a tidal volume of 10 mL/kg, respiratory rate of 70 rpm, and inspired oxygen fraction of 1. Animals were maintained under isoflurane anesthesia. After two hours, laparotomy was performed, and leukocyte-endothelial interactions were evaluated by intravital microscopy.

RESULTS

No significant changes were observed in mean arterial blood pressure among groups during the study. Tracheal peak pressure was smaller in PEEP 5 compared with PEEP 0 and PEEP 10 groups (11, 15, and 16 cmH2O, respectively; p<0.05). After two hours of MV, there were no differences among NAIVE, PEEP 0 and PEEP 5 groups in the number of rollers (118+/-9,127+/-14 and 147+/-26 cells/10 minutes, respectively), adherent leukocytes (3+/-1,3+/-1 and 4+/-2 cells/100 microm venule length, respectively), and migrated leukocytes (2+/-1,2+/-1 and 2+/-1 cells/5,000 microm(2), respectively) at the mesentery. However, the PEEP 10 group exhibited an increase in the number of rolling, adherent and migrated leukocytes (188+/-15 cells / 10 min, 8+/-1 cells / 100 microm and 12+/-1 cells / 5,000 microm(2), respectively; p<0.05).

CONCLUSIONS

High intrathoracic pressure was harmful to mesenteric microcirculation in the experimental model of rats with normal lungs and stable systemic blood pressure, a finding that may have relevance for complications related to mechanical ventilation.

Investigator-led clinical research consortia: the Canadian Critical Care Trials Group

Advances in the care of critically ill patients are dependent upon rigorous clinical research undertaken to characterize natural history and risk factors, and determine optimal approaches to the management of the diseases of the critically ill patient. The Canadian Critical Care Trials Group (CCCTG) was formed in 1989 to foster such research. It has grown to become a national, multidisciplinary organization with more than 100 members, and more than 3 dozen active research programs. Its members have been highly successful in obtaining funding for, completing, and publishing well-designed studies that have informed international practice in areas such as transfusion, stress ulcer prophylaxis, long term outcomes from acute respiratory distress syndrome, diagnosis and management of infection in the intensive care unit, and end-of-life care. In the process, the CCCTG has developed a highly effective culture of scientific mentoring, and has served as a model for investigator-led critical care research groups around the world. This review summarizes the history, activities, approaches, and challenges of the CCCTG, in the conviction that investigator-led groups such as ours represent the future of intensive care unit-based research.

Incidence and risk factors of upper gastrointestinal bleeding in mechanically ventilated children

OBJECTIVE

To identify the incidence and factors related to upper gastrointestinal (UGI) bleeding in children requiring mechanical ventilation for longer than 48 hrs.

DESIGN

Prospective analytic study.

SETTING

Ten-bed-pediatric intensive care unit of a tertiary care University Hospital.

PATIENTS

A total of 110 patients requiring mechanical ventilation for longer than 48 hrs from January 1, 2005 to December 31, 2005.

MEASUREMENTS AND RESULTS

UGI bleeding was defined by evidence of blood in nasogastric aspirates, hematemesis, or melena within 5 days of pediatric intensive care unit admission. We prospectively collected data on patient demographics, admission diagnosis, operative status, and pediatric risk of mortality score. UGI bleeding and the potential risk factors including organ failure, coagulopathy, maximum ventilator setting, enteral feeding, stress ulcer prophylaxis as well as sedation were daily monitored. Of the 110 patients who required mechanical ventilation for >48 hrs, the incidence of UGI bleeding was 51.8%, in which 3.6% of the cases presented with clinically significant bleeding (shock, requiring blood transfusion and/or surgery). Significant risk factors were thrombocytopenia, prolonged partial thromboplastin time, organ failure, high pressure ventilator setting >/=25 cm H2O, and pediatric risk of mortality score >/= 10 using univariate analysis. However, the independent factors of UGI bleeding in the multivariate analysis were organ failure (relative risk = 2.85, 95% confidence interval 1.18-6.92) and high pressure ventilator setting >/=25 cm H2O (relative risk = 3.73, 95% confidence interval 1.59-8.72).

CONCLUSION

The incidence of UGI bleeding is high in children requiring mechanical ventilation. Organ failure and high pressure ventilator setting are significant risk factors for UGI bleeding.

Strategies for success: A PDSA analysis of three QI initiatives in critical care

BACKGROUND

Implementation of evidence-based quality improvement (QI) initiatives is not without its challenges. Recent experience in the design, implementation, and evaluation of three QI initiatives at the University of California, San Francisco Medical Center (UCSF) suggests lessons learned that may be generalizable to other QI initiatives. INITIATIVES: Between December 2002 and May 2006, a ventilator bundle of care and a tight glycemic control (TGC) protocol were implemented in the intensive care units (ICUs), and early goal-directed therapy (EGDT) for patients with severe sepsis or septic shock was implemented in the ICUs and emergency department. The initiatives were selected on the basis of the magnitude of the problem, strength of the evidence regarding associated reductions in morbidity and mortality in the critically ill, and cost-effectiveness.

LESSONS LEARNED

A number of challenges in QI processes and strategies for success were identified via retrospective analysis within the construct of the Plan-Do-Study-Act model, representing a novel use of the model. Pitfalls most commonly occurred in the planning stage. Suggested strategies for success include using an interdisciplinary team, selecting a champion, securing additional resources, identifying specific goals and providing feedback on progress, using work-flow analyses and stepwise implementation and/or pilot testing, creating standard work, eliciting feedback from staff, and celebrating successes. The knowledge gained from these initiatives has been disseminated at UCSF, and the initiatives have helped to raise general awareness regarding the importance of quality.

CONCLUSIONS

The ventilator bundle of care, TGC, and EGDT are still in use at UCSF, with modification of the initiatives occurring as new evidence becomes available.

Gastrointestinal prophylaxis in critically ill patients

Physiologic stress associated with illness and hospitalization is known to result in gastrointestinal ulceration, especially among the critically ill. The complication of this stress-related mucosal disease could be prevented with appropriate application of pharmacologic prophylaxis. Vigilance by the nursing staff is required to properly detect and manage the condition.

Gastrointestinal dysfunction in the critically ill: can we measure it?

Gastrointestinal dysfunction is an intuitively important, yet descriptively elusive component of the multiple organ dysfunction syndrome. Reintam and colleagues have attempted to quantify this dimension using a combination of intolerance of enteral feeding, and the development of intra-abdominal hypertension. While they show that both parameters are associated with an increased risk of death (and therefore that, in combination, the risk of death is even greater), they fall short in developing a novel descriptor of gastrointestinal dysfunction. Nonetheless, and even with its shortcomings, their effort is a welcome contribution to the surprisingly complex process of describing the morbidity of critical illness.

The impact of clinical risk factors in the conversion from acute lung injury to acute respiratory distress syndrome in severe multiple trauma patients

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are different stages of the same disease, the aggravated stage of ALI leading to ARDS. Patients with ARDS have higher hospital mortality rates and reduced long-term pulmonary function and quality of life. It is, therefore, important to prevent ALI converting to ARDS. This study evaluated 17 risk factors potentially associated with the conversion from ALI to ARDS in severe multiple trauma. The results indicate that the impact of pulmonary contusion, APACHE II score, gastrointestinal haemorrhage and disseminated intravascular coagulation may help to predict conversion from ALI to ARDS in the early phase after multiple-trauma injury. Trauma duration, in particular, strongly impacted the short- and long-term development of ALI. Being elderly (aged > or = 65 years) and undergoing multiple blood transfusions in the early phase were independent risk factors correlated with secondary sepsis, deterioration of pulmonary function and transfusion-related acute lung injury due to early multiple fluid resuscitation.

Gastric mucosal defense and cytoprotection: bench to bedside

The gastric mucosa maintains structural integrity and function despite continuous exposure to noxious factors, including 0.1 mol/L HCl and pepsin, that are capable of digesting tissue. Under normal conditions, mucosal integrity is maintained by defense mechanisms, which include preepithelial factors (mucus-bicarbonate-phospholipid "barrier"), an epithelial "barrier" (surface epithelial cells connected by tight junctions and generating bicarbonate, mucus, phospholipids, trefoil peptides, prostaglandins (PGs), and heat shock proteins), continuous cell renewal accomplished by proliferation of progenitor cells (regulated by growth factors, PGE(2) and survivin), continuous blood flow through mucosal microvessels, an endothelial "barrier," sensory innervation, and generation of PGs and nitric oxide. Mucosal injury may occur when noxious factors "overwhelm" an intact mucosal defense or when the mucosal defense is impaired. We review basic components of gastric mucosal defense and discuss conditions in which mucosal injury is directly related to impairment in mucosal defense, focusing on disorders with important clinical sequelae: nonsteroidal anti-inflammatory drug (NSAID)-associated injury, which is primarily related to inhibition of cyclooxygenase (COX)-mediated PG synthesis, and stress-related mucosal disease (SRMD), which occurs with local ischemia. The annual incidence of NSAID-associated upper gastrointestinal (GI) complications such as bleeding is approximately 1%-1.5%; and reductions in these complications have been demonstrated with misoprostol, proton pump inhibitors (PPIs) (only documented in high-risk patients), and COX-2 selective inhibitors. Clinically significant bleeding from SRMD is relatively uncommon with modern intensive care. Pharmacologic therapy with antisecretory drugs may be used in high-risk patients (eg, mechanical ventilation >or=48 hours), although the absolute risk reduction is small, and a decrease in mortality is not documented.

Future expectations in the prophylaxis of intestinal bleeding

Prophylaxis of gastrointestinal bleeding is attempted in widely varying situations. In NSAID-induced peptic ulcer, the advantage of selective cyclooxygenase 2 inhibitors with regard to gastrointestinal damage has yet to be translated into an advantage in overall morbidity. Strategies for primary and secondary prevention of variceal bleeding have been established. Therapy tailored to hepatic venous pressure gradient has the potential to achieve clinical relevance. Several methods have been developed to prevent postpolypectomy bleeding, but their optimal risk-tailored application has yet to be demonstrated. Although octreotide treatment seems to be beneficial in reducing the blood loss from angiodysplasias, controlled studies to determine its optimal use are awaited. Stress-ulcer prophylaxis is commonly applied in critically ill patients. Although data indicate that H2-receptor antagonists and omeprazole are effective in preventing clinically significant bleeding, evidence for an advantage with respect to length of hospital or intensive-care-unit stay, as well as mortality, is still lacking. Since there is misuse of acid-suppressing drugs on regular wards, in-house guidelines may offer the potential for saving costs and reducing inappropriate prescription.

Famotidine Versus Pantoprazole for Preventing Bleeding in the Upper Gastrointestinal Tract of Critically Ill Patients Receiving Mechanical Ventilation

Background Mechanical ventilation increases risk for bleeding in the upper part of the gastrointestinal tract. Proton pump inhibitors, although they are more potent and longer acting inhibitors of gastric acid production than are histamine2 antagonists, also are generally more expensive. Data comparing the 2 types of agents for preventing gastrointestinal bleeding in critically ill patients are limited.

Objectives To compare the effectiveness of famotidine (a histamine2 antagonist) and pantoprazole (a proton pump inhibitor) in preventing stress ulcers in critically ill patients receiving mechanical ventilation.

Methods Data were collected from the Project Impact database. All patients who received mechanical ventilation for more than 48 hours from November 2002 to June 2006 and were treated with either drug were included. Patients receiving other drugs or with known bleeding in the upper part of the gastrointestinal tract, thrombocytopenia, or coagulopathy were excluded.

Results A total of 522 patients who received famotidine and 95 who received pantoprazole were included. Bleeding in the upper part of the gastrointestinal tract was more common in patients receiving pantoprazole than in patients receiving famotidine (0.38% vs 3.2%, P= .03). Although scores on the Acute Physiology and Chronic Health Evaluation II were higher in patients who received pantoprazole (P= .01), other outcome measures did not differ significantly between groups. Bleeding in the upper part of the gastrointestinal tract was more frequent among dialysis patients receiving pantoprazole than among those receiving famotidine.

Conclusions Famotidine and pantoprazole are similarly effective for preventing bleeding in the upper part of the gastrointestinal tract in patients receiving mechanical ventilation.

Therapy insight: Prophylaxis of stress-induced gastrointestinal bleeding in critically ill patients

Stress-induced gastrointestinal bleeding is associated with increased morbidity and mortality in critically ill patients. Within the past few decades, the incidence of stress-induced gastrointestinal bleeding has decreased. Prophylaxis of stress-induced gastrointestinal bleeding, which is aimed at preventing morbidity and mortality, has to be achieved with as few adverse effects as possible. Data indicate that not all critically ill patients need prophylaxis for stress-induced gastrointestinal bleeding. The main risk factors associated with clinically important hemorrhage are mechanical ventilation for >48 h, and coagulopathy (thrombocyte count <50/nl, partial thromboplastin time (PTT) >2 times the upper limit of the normal range, international normalized ratio (INR) >1.5). Ranitidine is more effective than sucralfate for the prevention of clinically important bleeding. Immediate-release omeprazole is as effective as cimetidine, and is more efficient at increasing the intragastric pH. As yet, however, there is no firm evidence that any of the drugs used for prophylaxis of stress-induced gastrointestinal bleeding in critically ill patients decrease mortality or the length of hospital stay. When to stop prophylaxis is decided on clinical grounds rather than on the basis of data from clinical studies.

Inappropriate continuation of stress ulcer prophylactic therapy after discharge

BACKGROUND

Medications for stress ulcer prophylaxis are appropriately started in critically ill patients with risks for developing stress ulcers. It is unknown whether these drugs are discontinued once the risk factors are removed.

OBJECTIVE

To assess the duration of stress ulcer prophylactic therapy in critically ill patients.

METHODS

A retrospective chart review was conducted at a multidisciplinary, 24 bed medical/surgical intensive care unit (ICU) of a university-affiliated tertiary referral medical center. Three hundred ninety-four patients fulfilled eligibility criteria during the study period of July 1, 2005, through September 30, 2005. Patients were considered to be appropriately discharged from the hospital on gastric acid suppressants if they met any of the following criteria: continued mechanical ventilation, gastroesophageal reflux disease, peptic ulcer disease, history of gastrointestinal ulceration or bleeding within the past year, prescribed medications used for stress ulcer prophylaxis prior to admission, gastrointestinal bleed during hospitalization, or prescriber indication of reason to continue therapy.

RESULTS

Three hundred fifty-seven patients received stress ulcer prophylaxis during their ICU stay. Of these, 80% continued on gastric acid suppressants on transfer from the ICU, with 60% of the therapy being inappropriate. The percentage of critically ill patients discharged from the hospital with inappropriate prescription of gastric acid suppressants was 24.4%. Based on the average wholesale cost, the total cost for unnecessary gastric acid suppressant therapy within the follow-up period was $13,973.

CONCLUSIONS

Gastric acid suppressant medications initially prescribed for stress ulcer prophylaxis are frequently prescribed inappropriately on discharge for patients who were initially admitted to the medical/surgical ICU.

Knowledge translation in critical care: factors associated with prescription of commonly recommended best practices for critically ill patients

OBJECTIVE

To describe prescription rates of commonly recommended best practices (clinical interventions with a strong base of evidence supporting their implementation) for critically ill patients and determine factors associated with increased rates of prescription.

DESIGN

A retrospective observational study.

SETTING

A university-affiliated medical-surgical-trauma intensive care unit over a 1-yr period.

PATIENTS

One hundred randomly selected critically ill patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Among the best practices studied, there was great variability in the proportion of patients eligible (median 36.5%, range 10% to 100%) and the proportion without contraindication (32.5%, range 10% to 86%) for each practice. The median rate of prescription of best practices for eligible patients was 56.5%, with a range from 8% to 95%. There was greater prescription of best practices when standard admission orders included an option to prescribe them (p = .048). Among those practices with standard admission orders, there was greatest prescription for practices additionally having a specialty consultation service (p = .004). There was an inverse association between severity of illness and prescription of best practices (p = .001): Sicker patients were less likely to be prescribed best practices.

CONCLUSIONS

There may be substantial variability in the acceptance and prescription of commonly recommended best practices for critically ill patients. Standard order sets and focused specialty consultation may improve knowledge translation and prescription of best practice.

Stress-related mucosal disease in the intensive care unit: an update on prophylaxis

Gastric ulcers have been known to develop in critically ill patients secondary to physiological stress since the 19th century. It is only relatively recently that stress ulcer prophylaxis has become an established routine practice in the intensive care unit. Numerous terms have been used to describe stress ulcers, but stress-related mucosal disease (SRMD) is commonly used. Significant morbidity and mortality in critically ill patients is caused by SRMD and related bleedings, but the incidence depends on the definition of bleeding. Pathophysiology of SRMD is multifactorial and involves a complex set of interactions that causes a breakdown of mucosal proactive defenses, leading to ulceration. Critically ill patients are at an increased risk for developing SRMD and subsequent bleeding secondary to several risk factors. To minimize stress-related mucosal bleeding, several regimens have been used. This article presents an update on the incidence, pathophysiology, risk factors, and prophylaxis of SRMD.

The 9-11 Commission's invitation to imagine: a pathophysiology-based approach to critical care of nuclear explosion victims

OBJECTIVE

The successful management of mass casualties arising from detonation of a nuclear device (NDD) would require significant preparation at all levels of the healthcare system. This article briefly outlines previously published models of destruction and casualties, details approaches to on-site triage and medical evacuation, and offers pathophysiology-based suggestions for treatment of the critically injured. Documentation from previous bomb blasts and nuclear accidents is reviewed to assist in forecasting needs of both systems and patients in the event of an NDD in a major metropolitan area.

DATA SOURCES/STUDY SELECTION

This review extracts data from previously published models of destruction and casualties projected from an NDD, the primary literature detailing observations of patients' pathophysiology following NDDs in Japan and relevant nuclear accidents, and available contemporary resources for first responders and healthcare providers.

DATA EXTRACTION/SYNTHESIS

The blast and radiation exposures that accompany an NDD will significantly affect local and regional public resources. Morbidity and mortality likely to arise in the setting of dose-dependent organ dysfunction may be minimized by rigorous a priori planning/training for field triage decisions, coordination of medical and civil responses to effect rapid responses and medical evacuation routes, radiation-specific interventions, and modern intensive care.

CONCLUSIONS

Although the responses of emergency and healthcare systems following NDD will vary depending on the exact mechanism, magnitude, and location of the event, dose exposures and individual pathophysiology evolution are reasonably predictable. Triage decisions, resource requirements, and bedside therapeutic plans can be evidence-based and can be developed rapidly with appropriate preparation and planning.

Nosocomial infections in the pediatric intensive care unit: affecting the impact on safety and outcome

OBJECTIVE

To define the most common types of nosocomial infections in critically ill children and to summarize the effect of methods to reduce their prevalence.

DESIGN

Review of published literature.

RESULTS

While in the pediatric intensive care unit, 16% of children develop a nosocomial infection. Processes affecting modifiable factors of care can reduce the prevalence of hospital-acquired infections.

CONCLUSIONS

The occurrence of a nosocomial infection represents failure and is not an acceptable outcome of treating critically ill children. Evidence-based process improvement can lead to significant reductions in hospital-acquired infections in children. Most of the processes and practices discussed are not novel or intriguing but, when performed routinely and appropriately, can lead to reductions in hospital-acquired infections.

Eliminating nosocomial infections at Ascension Health

BACKGROUND

Eliminating nosocomial infections was identified as one of eight priorities for action for Ascension Health. St. John Hospital and Medical Center (SJHMC), and St. Vincent's Hospital (STV), designated alpha sites, developed best practices for the prevention of catheter-related blood stream infections (CR-BSIs) and ventilator-associated pneumonia (VAP), respectively.

METHODS

Both hospitals used the Institute for Healthcare Improvement model of "bundles" to achieve the goal of reducing nosocomial infections and also implemented multidisciplinary rounds and the use of daily goal sheets in the intensive care unit (ICU).

RESULTS

Through the use of ventilator bundle, central line (CL) bundle, MDRs, and daily goal sheets, both facilities reduced CR-BSIs and VAPs by more than 50%.

DISCUSSION

SJHMC saw the benefit of having the physical presence of the ICPs in the ICUs, providing the staff with on-the-spot reinforcement of the initiative. STV found by starting the change process through the use of a flexible MDR team, the hospital was able to successfully implement positive changes in its ICU culture. On the basis of the success in the ICU, the concept of MDR teams eventually was adapted and spread to all units. Open communication among all patient caregivers was extended and served to provide improved patient care throughout the hospital.

The distinct clinical profile of chronically critically ill patients: a cohort study

Introduction

Our goal was to describe the epidemiology, clinical profiles, outcomes, and factors that might predict progression of critically ill patients to chronically critically ill (CCI) patients, a still poorly characterized subgroup.

Methods

We prospectively studied all patients admitted to a university-affiliated hospital intensive care unit (ICU) between 1 July 2002 and 30 June 2005. On admission, we recorded epidemiological data, the presence of organ failure (multiorgan dysfunction syndrome (MODS)), underlying diseases (McCabe score), acute respiratory distress syndrome (ARDS) and shock. Daily, we recorded MODS, ARDS, shock, mechanical ventilation use, lengths of ICU and hospital stay (LOS), and outcome. CCI patients were defined as those having a tracheotomy placed for continued ventilation. Clinical complications and time to tracheal decannulation were registered. Predictors of progression to CCI were identified by logistic regression.

Results

Ninety-five patients (12%) fulfilled the CCI definition and, compared with the remaining 690 patients, these CCI patients were sicker (APACHE II, 21 ± 7 versus 18 ± 9 for non-CCI patients, p = 0.005); had more organ dysfunctions (SOFA 7 ± 3 versus 6 ± 4, p < 0.003); received more interventions (TISS 32 ± 10 versus 26 ± 8, p < 0.0001); and had less underlying diseases and had undergone emergency surgery more frequently (43 versus 24%, p = 0.001). ARDS and shock were present in 84% and 83% of CCI patients, respectively, versus 44% and 48% in the other patients (p < 0.0001 for both). CCI patients had higher expected mortality (38% versus 32%, p = 0.003), but observed mortality was similar (32% versus 35%, p = 0.59). Independent predictors of progression to CCI were ARDS on admission, APACHE II and McCabe scores (odds ratio (OR) 2.26, p < 0.001; OR 1.03, p < 0.01; and OR 0.34, p < 0.0001, respectively). Lengths of mechanical ventilation, ICU and hospital stay were 33 (24 to 50), 39 (29 to 55) and 55 (37 to 84) days, respectively. Tracheal decannulation was achieved at 40 ± 19 days.

Conclusion

CCI patients were a severely ill population, in which ARDS, shock, and MODS were frequent on admission, and who suffered recurrent complications during their stay. However, their prognosis was equivalent to that of the other ICU patients. ARDS, APACHE II and McCabe scores were independent predictors of evolution to chronicity.

Brief report: Reducing inappropriate usage of stress ulcer prophylaxis among internal medicine residents. A practice-based educational intervention

BACKGROUND

Many inpatients receive stress ulcer prophylaxis (SUP) inappropriately. This indiscriminate usage increases costs and avoidable side-effects. Practice-based learning and improvement (PBLI) methodology may improve compliance with published guidelines.

OBJECTIVE

To investigate the response of internal medicine residents to an educational intervention regarding SUP.

DESIGN

A prospective, pre and postintervention cohort study using an educational intervention based on PBLI.

PATIENTS

Three groups of consecutively admitted patients (1 group preintervention and 2 groups postintervention) on the medicine ward at a University Hospital.

MAIN OUTCOME MEASURE

Rates of inappropriate SUP prescription and discharge with an inappropriate prescription.

RESULTS

One month after the intervention, inappropriate prophylaxis was significantly decreased (59% pre, 29% postintervention, P<.002). The rate of discharge with an inappropriate prescription also decreased, but was not significant (25% pre, 14% postintervention, P=.14). In the 6-month postintervention cohort, inappropriate SUP remained lower (59% pre, 33% postintervention, P<.007). The rate of discharge with an inappropriate prescription was also significantly lower (25% pre, 7% postintervention, P<.009).

CONCLUSION

Practice-based learning and improvement can improve compliance with published guidelines, and change practice patterns. After the intervention, both inappropriate prophylaxis and inappropriate prescriptions upon discharge were reduced. Importantly, the intervention was sustained, transmitted across academic years to a new class of interns who had not directly experienced the intervention.

Expression of Ghrelin in nervous system and its cytoprotective action in rats

AIM: To investigate the expression of Ghrelin in brain, intestinal myenteric plexus and plasma and study its possible cytoprotective effect and mechanism on gastric mucosa against stress-induced ulcers.

METHODS: Seventy-six healthy male Wistar rats were divided into 6 groups randomly: cold-water restraint group (n = 10); intracerebroventricular (icv) injection of Ghrelin group (n = 24); icv injection of Ghrelin after subcutaneous injection of Nω-Nitro-L-arginine methylester (L-NAME) group (n = 8) and three matched control groups. The expression of Ghrelin in rat brain, intestinal myenteric plexus and plasma were detected by radio-immunoassay (RIA) and double staining of immunofluorescence and immunohistochemistry. The effect and mechanism of Ghrelin on gastric mucosa against stress-induced ulcer were analyzed using neurophysiologic methods.

RESULTS: Ghrelin-positive immunoreaction (IR) was observed in the small intestinal myenteric plexus and primarily cultured myenteric plexus neurons. Ghrelin-IR co-localized with choline acetyl transferase (ChAT), but not with nitric oxide synthase (NOS) or Calbindin (Calb) in the same myenteric plexus neurons. In comparison with that in its matched control group, the content of Ghrelin-IR in plasma was significantly decreased (198.3 ± 29.6 ng/L vs 141.7 ± 26.5 ng/L, P < 0.05), but increased in hypothalamus, medulla oblongata, pituitary and intestinal myenteric plexus (96.2 ± 18.1 pg/mg vs 153.2 ± 11.6 pg/mg, P = 0.006; 89.8 ± 16.5 pg/mg vs 144.4 ± 13.9 pg/mg, P = 0.007; 108.3 ± 11.9 pg/mg vs 198.2 ± 23.3 pg/mg, P = 0.002; 48.8 ± 12.8 pg/mg vs 86.2 ± 21.5 pg/mg, P = 0.02; respectively). The formation of stress ulcers was markedly inhibited by microinjection of Ghrelin into the ventricle with a dose-dependent manner (ulcer index: normal saline 86.7 ± 6.2; 50 ng Ghrelin 79.3 ± 10.7, P = 2.18; 500 ng Ghrelin: 61.3 ± 11.7, P = 0.04; 5 000 ng Ghrelin: 35.6 ± 10.8, P = 0.005). However, after a subcutaneous injection of L-NAME, the cytoprotective effect of Ghrelin disappeared.

CONCLUSION: Ghrelin co-localizes with ChAT in intestinal myenteric plexus neurons. The expression of Ghrelin changes in the central nerves system (CNS) and plasma while stress ulcer happens. Ghrelin in the CNS can protect gastric mucosa with a dose-dependent manner, which is probably related to the synthesis of nitric oxide.

Hospital-acquired gastrointestinal bleeding outside the critical care unit: risk factors, role of acid suppression, and endoscopy findings

BACKGROUND

Risk factors for hospital-acquired gastrointestinal bleeding in the intensive care unit are established, and acid-suppressive prophylaxis has been advocated for certain subsets of critically ill patients. In contrast, risk factors and appropriate prevention strategies are not yet established for general medical patients. The objective of this study was to identify risk factors for nosocomial gastrointestinal bleeding (GIB) in non-critically ill medical patients, to evaluate the utility of prophylactic gastric acid suppression, and to characterize the endoscopic lesions.

METHODS

This was a retrospective case-control study that took place at a U.S. tertiary care center. All patients admitted to the General Medicine ward for nongastrointestinal disorders who developed clinically relevant gastrointestinal bleeding during admission or within 4 weeks of discharge were considered cases. Clinically relevant bleeding was defined as any bleeding requiring esophagogastroduodenoscopy (EGD). Random controls were matched to cases by date of hospitalization in a 1:1 ratio. Clinical information was extracted by chart review.

RESULTS

Of 17,707 patients admitted to the General Medicine ward over a 4-year period, 73 (0.41%) met the case definition. The main risk factor for nosocomial GIB was treatment with full dose anticoagulants or clopidogrel (OR = 5.4; 2.6-11.7; P < .0001). Use of aspirin, nonsteroidal anti-inflammatory medications, and glucocorticoids did not differ significantly between cases and controls. De novo acid-suppressive prophylaxis was not protective (OR = 1.0; 95% CI: 0.4-2.4; P = 0.97). Endoscopic abnormalities were noted in 74% of patients; many cases had lesions unlikely to be prevented by acid blockade.

CONCLUSIONS

Hospital-acquired gastrointestinal bleeding is uncommon in non-critically ill patients. Anticoagulation appears to be the most important risk factor for nosocomial GIB. Routine use of acid suppressant medications for prophylaxis is unnecessary in most hospitalized patients.

Anticoagulant prophylaxis in special populations with an indwelling epidural catheter or renal insufficiency

The prevention of deep venous thrombosis in postoperative patients who have an indwelling epidural catheter and patients with impaired renal function is a frequently encountered and challenging clinical management problem. Such patients make up a considerable proportion of patients in a medical-surgical intensive care unit. The management of such patients is problematic because low-molecular-weight heparins, the anticoagulant of choice as thromboprophylaxis for many clinical indications, are generally avoided in such patients. This review focuses on anticoagulant prophylaxis in such patients, including reasonable approaches for using low-molecular-weight heparins as thromboprophylaxis.

Review article: prevention of stress-related mucosal bleeding with proton-pump inhibitors

Stress-related gastric mucosal bleeding occurs in a substantial number of critically ill patients, with clinically important gastrointestinal bleeding prolonging intensive care stay and increasing mortality. This paper reviews the role of proton-pump inhibitors in the prevention of stress-related mucosal bleeding. Bleeding prophylaxis appears to be warranted in patients in intensive care units on mechanical ventilation or those who have coagulopathy. Intravenous histamine H2 receptor antagonists, particularly cimetidine, have demonstrated efficacy for the prevention of bleeding in critically ill patients. Standard delayed-release proton-pump inhibitors have not been extensively studied in this patient group, but there are some data to support their efficacy in increasing intragastric pH, and in the case of intravenous pantoprazole in preventing gastrointestinal bleeding. In a large, randomized controlled trial, immediate-release omeprazole [(IR-OME) Zegerid powder for oral suspension; Santarus Inc., San Diego, CA, USA] administered via gastric tube, was as effective as intravenous cimetidine in the prevention of clinically significant bleeding, and more effective in increasing gastric pH. Effective antisecretory therapy does not appear to increase the risk of nosocomial pneumonia. In conclusion, immediate-release omeprazole provides a safe and effective alternative to intravenous cimetidine for the prevention of stress-related mucosal bleeding in critically ill patients.

The impact of implementing an enteral tube feeding protocol on caloric and protein delivery in intensive care unit patients

BACKGROUND

The purpose of this study was to determine the effect of an enteral tube feeding protocol on caloric and protein delivery to intensive care unit (ICU) patients.

METHODS

This prospective study consisted of 2 phases: before and after the implementation on an enteral-feeding protocol. The following data were collected: demographics, Acute Physiology and Chronic Health Evaluation II score and Simplified Acute Physiology Score II, caloric and protein requirements, the location of the feeding tube tip, and prokinetic agents use. The primary endpoint was caloric and protein intake as a percentage of the requirement. Secondary endpoints were gastric residuals >150 mL, vomiting episodes, ICU and hospital lengths of stay, mechanical ventilation duration, and ICU and hospital mortality.

RESULTS

There were no significant differences between the control (n = 100) and protocol groups (n = 103) in baseline characteristics. The protocol was associated with significant improvement in the 7-day average of caloric intake/requirement (53.9 +/- 2.3% vs 64.5 +/- 2.2%, p = .001) and protein intake/requirement (56.7 +/- 2.6% vs 67.4% +/- 2.7%, p = .005). Caloric and protein intake improved whether the patient was receiving prokinetic agent or not. There was a trend toward lower gastric residual volumes and vomiting episodes in the protocol group. Patients receiving gastric feeding showed significant improvement in caloric intake to levels comparable to patients with postpyloric feeding.

CONCLUSIONS

Enteral tube feeding protocol is effective in improving feeding delivery in ICU patients independent of prokinetic agent use. Protocol for enteral tube feeding should be considered in the management of ICU patients, given the positive impact of this nonpharmacologic, non-interventional tool.

Collaboratively Designed Practice Guidelines Promote Appropriate Use of Intravenous Proton Pump Inhibitors

Objective

To determine the effectiveness of practice guidelines for proton pump inhibitor use at an academic medical center.

Methods

Patients initiated on intravenous (IV) pantoprazole therapy between July 2001 and May 2002 were evaluated prospectively for appropriateness of therapy. Pharmacists assessed clinical use, dosing strategy, administration route, and prescribing patterns.

Results

A total of 85 patients were evaluated. Only 25% of the patients were prescribed IV pantoprazole according to established institutional guidelines. The majority of therapy meeting guideline criteria were initiated on pantoprazole by the Gastroenterology service. Due to overuse of pantoprazole, prescribing guidelines were revised to specify indications with proven efficacy (erosive GERD, Zollinger-Ellison or other hypersecretory conditions, and upper gastrointestinal bleeding). Patients who received pantoprazole for stress ulcer prophylaxis, an unapproved indication, had therapy automatically switched to a histamine receptor antagonist. For patients who tolerated oral medications or enteral feedings, therapy was automatically converted to the oral dosage form.

Conclusions

Evaluation of institutional pantoprazole utilization revealed usage extending beyond indications with proven efficacy. Pharmacists and physicians collaboratively developed evidence-based practice guidelines; adherence to appropriate indications showed a 50% improvement.

Contemporary strategies for the prevention of stress-related mucosal bleeding

PURPOSE

The purpose of this review is to describe the clinical presentation and pathophysiology of stress-related mucosal bleeding and review the strategies to prevent bleeding.

SUMMARY

The mortality rate associated with clinically significant stress-related mucosal bleeding is high. Respiratory failure requiring mechanical ventilation for more than 48 hours and coagulopathy are two strong, independent risk factors for bleeding. Splanchnic hypoperfusion is the underlying etiology of stress-related mucosal injury and bleeding. Mucosal damage typically manifests as multiple superficial lesions without perforation, and bleeding often originates in superficial capillaries after the patient is admitted to the intensive care unit. Providing adequate visceral perfusion is vital to preventing bleeding. Gastrointestinal function should be taken into consideration before using enteral nutrition, and enteral nutrition should not be the sole stress ulcer prophylactic therapy. Acid-suppression therapy should be used to raise the intragastric pH above 3.5 because it reduces the incidence of stress-related mucosal bleeding. Proton pump inhibitors are at least as effective, and may be more effective than histamine H2-receptor antagonists in achieving this pH goal and preventing bleeding.

CONCLUSION

The key to reducing mortality from stress-related bleeding in critically ill patients is to prevent mucosal damage. Providing adequate visceral perfusion and acid-suppression therapy can reduce the risk of stress-related mucosal damage and bleeding.

Prevention of stress ulceration: current trends in critical care

OBJECTIVE

To identify the level of current intensivist's knowledge regarding risk assessment and intensive care unit (ICU) clinical practice pertaining to stress-related mucosal bleeding, including pharmacologic approaches for stress ulcer prevention.

DESIGN

A nationwide survey of critical care physicians.

STUDY POPULATION

Two thousand random physician members of the Society of Critical Care Medicine.

MEASUREMENTS AND MAIN RESULTS

The response rate was 519 (26%) of 2000, with data analysis from 501 (25.1%) usable surveys. Respondents were affiliated with internal medicine (44.3%), surgery (42.3%), and anesthesiology (12.6%). Gut ischemia was indicated as the perceived major cause of stress ulceration (59.7%). The estimated incidence of clinically important bleeding was 2% or less by 62% of respondents; however, 28.6% of physicians surveyed initiate stress ulcer prophylaxis in all ICU patients, regardless of bleeding risk. Respiratory failure was most frequently indicated as a reason for stress ulcer prophylaxis (68.6%), followed by shock/hypotension (49.4%), sepsis (39.4%), and head injury/major neurologic insult (35.2%). The first-line agents selected for stress ulcer prophylaxis include histamine-2 receptor antagonists (63.9%), followed by proton pump inhibitors (23.1%), and sucralfate (12.2%). Concern for nosocomial pneumonia was regarded as more prevalent with antisecretory therapies in those who chose sucralfate (61%) as initial therapy compared with overall respondents (26.9%) (p < .001).

CONCLUSIONS

The majority of intensivists surveyed recognize stress-related mucosal bleeding as a relatively infrequent event; however, implementation of a stress ulcer prophylaxis risk stratification scheme for ICU patients is necessary. Histamine-2 receptor antagonists are consistently perceived as appropriate initial agents, although proton pump inhibitors have become first-line therapy in an increasing percentage of critical care patients, despite limited data regarding their use in this population.

Do proton pump inhibitors increase the incidence of nosocomial pneumonia and related infectious complications when compared with histamine-2 receptor antagonists in critically ill trauma patients?

BACKGROUND

Proton pump inhibitors (PPI) may increase the risk of nosocomial pneumonia caused by profound irreversible gastric acid suppression. The study purpose was to characterize differences in nosocomial pneumonia and related infections in trauma patients administered either histamine2-receptor antagonists (H2RA) or PPI.

METHODS

Observational evaluation of consecutive critically ill adult trauma patients administered either omeprazole or famotidine during a 22-month period. Nosocomial infection was evaluated daily based on published CDC definitions.

RESULTS

Eighty of 269 patients fulfilled study criteria. The PPI group (n = 40) exhibited increased baseline risk for infection, demonstrated by higher ISS (p = 0.020), more chest tube placements (p = 0.031), and increased chest trauma (p = 0.025). Overall number of patients infected per group included 33% and 40% of patients administered PPI and H2RA, respectively (p = 0.64). Despite baseline differences, the incidence of nosocomial infection was similar (p = 0.87), and extrapolation of pneumonia based on 1000 patient days revealed a ratio 51.7 vs 52.2 in the PPI vs H2RA groups, respectively, which was not significant (p = 0.99).

CONCLUSIONS

Proton pump inhibitor administration does not increase risk of nosocomial pneumonia or other nosocomial infections compared with H2RA therapy in the critically ill trauma patient.

Stress-related mucosal disease: risk factors and prophylactic therapy

BACKGROUND

The term stress-related mucosal disease (SRMD) represents a continuum of conditions ranging from stress-related injury (superficial mucosal damage) to stress ulcers (focal deep mucosal damage). Caused by mucosal ischemia, SRMD is most commonly seen in critically ill patients in the intensive care unit (ICU). Prophylaxis of stress ulcers may reduce major bleeding but has not yet been shown to improve survival.

OBJECTIVES

This article reviews currently available agents for the prophylaxis of SRMD and discusses their uses and potential adverse effects.

METHODS

Relevant articles in the English-language literature were identified through a MEDLINE search (1968-2003) using the key words stress-related mucosal disease, stress-related injury, ulcer, prophylaxis, intensive care unit, and upper gastrointestinal bleeding.

RESULTS

The most widely used drugs for stress-related injury are the intravenous histamine(2)-receptor antagonists. These drugs raise gastric pH but are associated with the development of tolerance and possible drug interactions and neurologic manifestations. Sucralfate, which can be administered by the nasogastric route, can protect the gastric mucosa without raising pH, but may decrease the absorption of concomitantly administered oral medications. The prostaglandin misoprostol has not been shown to be of benefit in the prophylaxis of SRMD. Antacids lower the risk of gastrointestinal bleeding, but large volumes of antacids are required and treatment is labor intensive. Proton pump inhibitors (PPIs) are the most potent acid-suppressive pharmacologic agents available. Esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole substantially raise gastric pH for up to 24 hours after a single dose. The availability of an intravenous formulation of pantoprazole may help improve the treatment of SRMD in ICU patients, particularly those receiving mechanical ventilation. Tolerance does not develop, and few adverse effects have been reported.

CONCLUSIONS

Recent studies of PPIs have shown promising results in high-risk patients, making this class of drugs an option for the prophylaxis of SRMD.

Outcomes in critically ill patients before and after the implementation of an evidence-based nutritional management protocol

OBJECTIVE

To determine whether the implementation of a nutritional management protocol in the ICU leads to the increased use of enteral nutrition, earlier feeding, and improved clinical outcomes in patients.

DESIGN

Prospective evaluation of critically ill patients before and after the introduction of an evidence-based guideline for providing nutritional support in the ICU.

SETTING

The medical-surgical ICUs of two teaching hospitals.

PATIENTS

Two hundred critically ill adult patients who remained npo > 48 h after their admission to the ICU. One hundred patients were enrolled into the preimplementation group, and 100 patients were enrolled in the postimplementation group.

INTERVENTION

Implementation of an evidence-based ICU nutritional management protocol.

MEASUREMENT AND RESULTS

Nutritional outcome measures included the number of patients who received enteral nutrition, the time to initiate nutritional support, and the percent caloric target administered on day 4 of nutritional support. Clinical outcomes included the duration of mechanical ventilation, ICU and in-hospital length of stay (LOS), and in-hospital mortality rates. Patients in the postimplementation group were fed more frequently via the enteral route (78% vs 68%, respectively; p = 0.08), and this difference was statistically significant after adjusting for severity of illness, baseline nutritional status, and other factors (odds ratio, 2.4; 95% confidence interval [CI], 1.2 to 5.0; p = 0.009). The time to feeding and the caloric intake on day 4 of nutritional support were not different between the groups. The mean (+/- SD) duration of mechanical ventilation was shorter in the postimplementation group (17.9 +/- 31.3 vs 11.2 +/- 19.5 days, respectively; p = 0.11), and this difference was statistically significant after adjusting for age, gender, severity of illness, type of admission, baseline nutritional status, and type of nutritional support (p = 0.03). There was no difference in ICU or hospital LOS between the two groups. The risk of death was 56% lower in patients who received enteral nutrition (hazard ratio, 0.44; 95% CI, 0.24 to 0.80; p = 0.007).

CONCLUSION

An evidence-based nutritional management protocol increased the likelihood that ICU patients would receive enteral nutrition, and shortened their duration of mechanical ventilation. Enteral nutrition was associated with a reduced risk of death in those patients studied.

Upper gastrointestinal haemorrhage following cardiac surgery: a comparative study with vascular surgery patients from a single centre

OBJECTIVE

To compare the frequency and outcome of upper gastrointestinal haemorrhage (UGH) patients who had undergone cardiac surgery with a control group of vascular surgery patients.

PATIENTS

Patients who had undergone cardiac or vascular surgery from January 1999 to December 2000 were identified from departmental records. The inclusion criteria used were haematemesis and/or melaena in the post-operative period.

RESULTS

Only 20 of the 2274 (0.9%) cardiac operations were complicated by UGH compared to eight of 708 (1.1%) vascular operations. Among those with UGH, 90% of the cardiac and 43% of the vascular patients were taking aspirin, warfarin or both. The mean interval between surgery and the UGH was 9.6 days (range 1-30) for the cardiac and 6 days (range 0-15) for the vascular patients. Duodenal and gastric ulcers were the most common cause of UGH (60%) in the cardiac group. Despite endoscopic intervention, more than one third of ulcer associated haemorrhages required surgical over-sewing, but none of the patients who had surgery died. The overall mortality on the cardiac surgery patients who experienced UGH was 15%, significantly higher than the 2.3% for the whole cardiac surgery group during the study period (P = 0.00075, OR = 8, 95% confidence interval 2.3-28). However, even this mortality is less than that of general inpatients who suffer UGH (33%).

CONCLUSIONS

Cardiac and vascular surgical patients have similar low post-operative rate of UGH. Post-operative UGH is associated with increased mortality after primary surgery. Early surgical intervention appears to be life saving in those patients who are too ill to compensate for the haemodynamic disturbance of untreated UGH.

Bleeding duodenal ulcer: comparison between Helicobacter pylori positive and Helicobacter pylori negative bleeders

BACKGROUND AND AIMS

To provide a direct comparison of Helicobacter pylori-positive subjects bleeding from duodenal ulcer with H. pylori-negative ones, in terms of severity of bleeding and outcome.

PATIENTS AND METHODS

A case-control study was prospectively conducted in 105 H. pylori-negative duodenal ulcer bleeders and same number of sex- and age-matched H. pylori-positive ones.

RESULTS

NSAID consumption was more common among H. pylori-negative subjects (81%) compared to their H. pylori-positive counterparts (58.1%, P < 0.001). H. pylori-negative bleeders were found to need more often haemostasis (55.2% versus 31.4%, P < 0.001) or surgical intervention (15.2% versus 4.8%, P = 0.011) and to have a greater proportion of rebleeding (32.4% versus 13.3%, P = 0.001), a more prolonged hospitalisation (11.6 +/- 4.1 versus 6.2 +/- 1.5 days, P < 0.001) and a higher rate of in-hospital mortality (15.2% versus 3.8%, P = 0.005). In the overall population (N = 210), H. pylori negativity, among other known risk factors, emerged as independent predictor (odds ratio: 3.2; 95% CI: 1.5, 11.2; P = 0.004) of an unfavourable outcome (surgery or death).

CONCLUSIONS

Duodenal ulcer bleeding in H. pylori-negative subjects appears to be more severe, to have a higher rate of rebleeding, and to lead more often to surgery or fatality compared to the vast majority of H. pylori-positive duodenal ulcer bleeders.

Anaemia and red blood cell transfusion in the critically ill patient

Anaemia is a common finding in critically ill patients. There are often multiple causes. Obvious causes include surgical bleeding and gastrointestinal haemorrhage but many patients have no overt bleeding episodes. Phlebotomy can be a significant source of blood loss. In addition, critically ill patients have impaired erythropoiesis as a consequence of blunted erythropoietin production and direct inhibitory effects of inflammatory cytokines. The ability of a patient to tolerate anaemia depends on their clinical condition and the presence of any significant co-morbidity; maintenance of circulating volume is of paramount importance. There is no universal transfusion trigger. Current guidelines for critically ill and perioperative patients advise that at Hb values <70 g/L red blood cell transfusion is strongly indicated and at Hb values >100 g/L transfusion is unjustified. For patients with Hb values in the range 70 to 100 g/L the transfusion trigger should be based on clinical indicators. Most stable critically ill patients can probably be managed with a Hb concentration between 70 and 90 g/L. Uncertainties exist concerning the most appropriate Hb concentration for patients with significant cardio-respiratory disease.

Urgent bedside endoscopy for clinically significant upper gastrointestinal hemorrhage after admission to the intensive care unit

OBJECTIVE

To investigate the sources of hemorrhage and use of endoscopic hemostasis in patients with clinically significant upper gastrointestinal (UGI) hemorrhage after admission to the intensive care unit (ICU).

DESIGN AND SETTING

Prospective study, 123 beds of ICU in a 1,629-bed medical center.

MEASUREMENTS AND RESULTS

Of the 9,512 consecutive admissions over a 2-year period 105 UGI hemorrhage patients underwent urgent bedside UGI endoscopy. We compared two groups of these patients, one receiving and the other not receiving endoscopic hemostasis. Ulcers with profusely bleeding stigmata occurred in 31 patients (29.5%), ulcers with clean bases or firmly adherent blood clots in 27 (25.7%), stress-related mucosal diseases in 23 (21.9%), esophageal varices in 5 (4.8%), malignancy in 4 (3.8%), and no detectable bleeding site in 15 (14.3%). Endoscopic hemostasis was attempted in 34 patients (32.4%). Primary hemostasis for them was achieved in 67.6% and the rebleeding rate was 30.4%. In-hospital mortality rate was 77.1% and death related to hemorrhage 6.2%. Length of ICU stay before endoscopic diagnosis was significantly shorter in those who underwent endoscopic hemostasis than those who did not (28.2+/-26.3 vs. 41.2+/-57.5 days).

CONCLUSIONS

Endoscopic hemostasis may be more beneficial when the period between ICU admission and development of hemorrhage is shorter. Bleeders can be more readily identified and controlled endoscopically in such patients. A significant proportion of bleeding sites cannot be identified by UGI endoscopy. It may indicate higher risk of small bowel hemorrhage in these critically ill patients.

Risk factors for upper gastrointestinal bleeding among end-stage renal disease patients

BACKGROUND

The risk of upper gastrointestinal bleeding (UGIB) is increased among end-stage renal disease (ESRD) patients compared to the general population. However, correlates of UGIB among ESRD patients remain unknown. We conducted a cohort study of dialysis patients to ascertain risk factors for UGIB.

METHODS

Data from the United States Renal Data System Dialysis Morbidity and Mortality Studies, Waves 2-4 were used to identify risk factors for incident UGIB among ESRD patients. First hospitalizations for UGIB were identified using hospital diagnosis codes between 12/31/93 and 12/31/99. Cox regression was used to estimate the association between predictors of interest and first diagnosis of UGIB.

RESULTS

Cases of UGIB (698) were observed over 30648 patient years of follow-up. Before adjustment for confounding factors, increasing age, diabetes, former and current smoking, cardiovascular disease (CVD), lower serum albumin, malnutrition, and inability to ambulate independently were associated with an increased risk of UGIB, while African Americans and transplant patients had a lower risk of UGIB. After adjustment, African American race was associated with a lower risk of UGIB (RR = 0.90; 0.82, 0.98), while current smoking (RR = 1.11; confidence interval 1.03, 1.19), history of CVD (RR = 1.32; 1.10, 1.59), and inability to ambulate independently (RR = 1.32; 1.07, 1.63) were associated with a higher risk of UGIB. Age, gender, diabetes, lower serum albumin, nourishment, treatment modality, aspirin use, nonsteroidal anti-inflammatory drug (NSAID) use, and antiplatelet or anticoagulant medication use were not found to be significantly related to the risk of UGIB after adjustment for potential confounding factors.

CONCLUSION

CVD, current smoking, and risk factors suggesting more disability are associated with a greater risk of UGIB among patients with ESRD.

Clinically significant gastrointestinal bleeding in critically ill patients with and without stress-ulcer prophylaxis

OBJECTIVE

To compare the rates of clinically significant gastrointestinal bleeding and the number of blood units and endoscopies required for gastrointestinal hemorrhage between patients receiving or not receiving stress-ulcer prophylaxis.

DESIGN

Historical observational study comparing two consecutive periods: with (phase 1) and without stress-ulcer prophylaxis (phase 2).

DESIGN AND SETTING

A 17-bed intensive care unit in a university teaching hospital. PATIENTS. In phase 1 there were 736 patients and in phase 2737. Those in the two phases were comparable in age and reason for admission; clinically significant gastrointestinal bleeding rates did not differ between the two phases, but patients in phase 2 were more severely ill.

MEASUREMENTS AND RESULTS

Comparable numbers of blood units were transfused per bleeding patient in the two phases, especially for patients with significant gastrointestinal bleeding. During each phase 19 fibroscopies were performed for significant bleeding, and two patients required surgery. The clinically significant gastrointestinal bleeding rate and outcome did not differ in patients with at least one risk factor. Total expenditures directly related to gastrointestinal bleeding were similar during the two phases; the total cost incurred by stress-ulcer prophylaxis was estimated at 6700.

CONCLUSIONS

Our results suggest that stress-ulcer prophylaxis does not influence the clinically significant gastrointestinal bleeding rate in intensive care unit patients or the cost of its management.

Evidence-based analysis: postoperative gastric bleeding: etiology and prevention

Although the incidence of stomach hemorrhage is declining, stress-related gastric bleeding remains an important source of morbidity and mortality in cancer patients undergoing major surgical procedures to remove tumor. Prevention of stress-related bleeding is desirable; however, the optimal use of drugs to prevent gastric bleeding is unclear. Prophylaxis is recommended for surgical patients who require prolonged mechanical ventilation or have a coaguloathy. Histamine-2 receptor antagonists and sucralfate will reduce the likelihood of clinically important gastric-bleeding. Sucralfate appears to be less effective than H-2 blockers, but it is associated with fewer side effects such as nosocomial pneumonia. Preliminary studies show that proton pump inhibitors are most effective, have few side effects, but are most expensive. Intravenous proton pump inhibitors may be the drugs of choice for stress ulcer prophylaxis (SUP) in high-risk patients.