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Abstract
Stress ulcer prophylaxis (SUP) with acid-suppressive drug therapy is widely utilized in critically ill patients following neurologic injury for the prevention of clinically important stress-related gastrointestinal bleeding (CIB). Data supporting SUP, however, largely originates from studies conducted during an era where practices were vastly different than what is considered routine by today's standard. This is particularly true in neurocritical care patients. In fact, the routine provision of SUP has been challenged due to an increasing prevalence of adverse drug events with acid-suppressive therapy and the perception that CIB rates are sparse. This narrative review will discuss current controversies with SUP as they apply to neurocritical care patients. Specifically, the pathophysiology, prevalence, and risk factors for CIB along with the comparative efficacy, safety, and cost-effectiveness of acid-suppressive therapy will be described.
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Granholm A, Zeng L, Dionne JC, Perner A, Marker S, Krag M, MacLaren R, Ye Z, Møller MH, Alhazzani W. Predictors of gastrointestinal bleeding in adult ICU patients: a systematic review and meta-analysis. Intensive Care Med 2019; 45:1347-1359. [DOI: 10.1007/s00134-019-05751-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 08/15/2019] [Indexed: 12/29/2022]
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Wei J, Jiang R, Li L, Kang D, Gao G, You C, Zhang J, Gao L, Huang Q, Luo D, Zhao G, Zhang H, Wang S, Wang R. Stress-related upper gastrointestinal bleeding in adult neurocritical care patients: a Chinese multicenter, retrospective study. Curr Med Res Opin 2019; 35:181-187. [PMID: 29499622 DOI: 10.1080/03007995.2018.1448261] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE China has limited data on stress-related gastrointestinal ulcers in patients admitted for neurosurgical care. This study evaluated the incidence of upper gastrointestinal bleeding (UGIB) and use of stress ulcer prophylaxis (SUP) in Chinese neurocritical care patients (Glasgow Coma Scale [GCS] score ≤10). METHODS This multicenter, retrospective study was performed from January 2015 to July 2015. Medical records of 1468 patients hospitalized during 2014 were reviewed. An estimated UGIB incidence rate of 4.4% was considered for precision of 1.3% for estimation of UGIB. The primary endpoint was evaluation of overall incidence of any overt UGIB in ≤14 days after cerebral lesion. Secondary endpoints included incidence of UGIB with or and without clinically significant complications, time to UGIB, associated risk factors and SUP used. RESULTS We analyzed 1416 patients (mean age: 53.7 ± 14.00 years; males: 62.4%) with cerebral lesions. Overall incidence rate of UGIB ≤14 days was 12.9% (95% CI: 11.2%-14.7%), 0.76% with and 12.1% without significant clinical complications. Average time and duration of bleeding were 2.9 ± 3.37 days and 4.2 ± 8.4 days, respectively. The most significant risk factors for UGIB were mechanical ventilation for >48 hours (p < .0001), UGIB history (p = .0026) and use of anticoagulants (p < .0001). Acid-suppression drugs were administered for SUP in 79.0% of the patients, whereas 40.5% received hemostatic drugs. CONCLUSIONS The rate of UGIB incidence was higher than the estimated rate in neurocritical care patients in China, suggesting the need for better management and treatment for stress-related mucosal disease in China. History of UGIB, mechanical ventilation and/or anticoagulants significantly affected UGIB. ClinicalTrials registry number: NCT02316990.
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Affiliation(s)
- Junji Wei
- a Department of Neurosurgery , Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College , Beijing , China
| | - Rongcai Jiang
- b Department of Neurosurgery , Tianjin Medical University General Hospital , Tianjin , China
| | - Lihong Li
- c Department of Neurosurgery , Tangdu Hospital of the Fourth Military Medical University , Xi'an , China
| | - Dezhi Kang
- d Department of Neurosurgery , the First Affiliated Hospital of Fujian Medical University , Fuzhou , China
| | - Guodong Gao
- c Department of Neurosurgery , Tangdu Hospital of the Fourth Military Medical University , Xi'an , China
| | - Chao You
- e Department of Neurosurgery, West China School of Medicine/West China Hospital , Sichuan University , Chengdu , China
| | - Jianmin Zhang
- f Department of Neurosurgery, the Second Affiliated Hospital of Zhejiang University School of Medicine , Hangzhou , China
| | - Liang Gao
- g Department of Neurosurgery , Shanghai Tenth People's Hospital/Tenth People's Hospital of Tongji University , Shanghai , China
| | - Qibing Huang
- h Department of Neurosurgery , Qilu Hospital of Shandong University , Jinan , China
| | - Duanwu Luo
- i Department of Neurosurgery , Xiangya Hospital Central South University , Changsha , China
| | - Gang Zhao
- j Department of Neurosurgery , the First Hospital of Jilin University , Changchun , China
| | - Hongyi Zhang
- k Department of Neurosurgery , Tangshan Gongren Hospital , Tangshan , China
| | - Shuo Wang
- l Department of Neurosurgery , Beijing Tian Tan Hospital, Capital Medical University , Beijing , China
| | - Renzhi Wang
- a Department of Neurosurgery , Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College , Beijing , China
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KRAG M, PERNER A, WETTERSLEV J, MØLLER MH. Stress ulcer prophylaxis in the intensive care unit: is it indicated? A topical systematic review. Acta Anaesthesiol Scand 2013; 57:835-47. [PMID: 23495933 DOI: 10.1111/aas.12099] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2013] [Indexed: 12/18/2022]
Abstract
UNLABELLED Stress ulcer prophylaxis (SUP) is regarded as standard of care in the intensive care unit (ICU). However, recent randomized, clinical trials (RCTs) and meta-analyses have questioned the rationale and level of evidence for this recommendation. The aim of the present systematic review was to evaluate if SUP in the critically ill patients is indicated. DATA SOURCES MEDLINE including MeSH, EMBASE, and the Cochrane Library. PARTICIPANTS patients in the ICU. INTERVENTIONS pharmacological and non-pharmacological SUP. STUDY APPRAISAL AND SYNTHESIS METHODS Risk of bias was assessed according to Grading of Recommendations Assessment, Development, and Evaluation, and risk of random errors in cumulative meta-analyses was assessed with trial sequential analysis. A total of 57 studies were included in the review. The literature on SUP in the ICU includes limited trial data and methodological weak studies. The reported incidence of gastrointestinal (GI) bleeding varies considerably. Data on the incidence and severity of GI bleeding in general ICUs in the developed world as of today are lacking. The best intervention for SUP is yet to be settled by balancing efficacy and harm. In essence, it is unresolved if intensive care patients benefit overall from SUP. The following clinically research questions are unanswered: (1) What is the incidence of GI bleeding, and which interventions are used for SUP in general ICUs today?; (2) Which criteria are used to prescribe SUP?; (3) What is the best SUP intervention?; (4) Do intensive care patients benefit from SUP with proton pump inhibitors as compared with other SUP interventions? Systematic reviews of possible interventions and well-powered observational studies and RCTs are needed.
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Affiliation(s)
- M. KRAG
- Department of Intensive Care; Copenhagen University Hospital; Rigshospitalet; Denmark
| | - A. PERNER
- Department of Intensive Care; Copenhagen University Hospital; Rigshospitalet; Denmark
| | - J. WETTERSLEV
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen University Hospital; Rigshospitalet; Denmark
| | - M. H. MØLLER
- Department of Intensive Care; Copenhagen University Hospital; Rigshospitalet; Denmark
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Osman D, Djibré M, Da Silva D, Goulenok C. Management by the intensivist of gastrointestinal bleeding in adults and children. Ann Intensive Care 2012; 2:46. [PMID: 23140348 PMCID: PMC3526517 DOI: 10.1186/2110-5820-2-46] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 10/05/2012] [Indexed: 12/12/2022] Open
Abstract
Intensivists are regularly confronted with the question of gastrointestinal bleeding. To date, the latest international recommendations regarding prevention and treatment for gastrointestinal bleeding lack a specific approach to the critically ill patients. We present recommendations for management by the intensivist of gastrointestinal bleeding in adults and children, developed with the GRADE system by an experts group of the French-Language Society of Intensive Care (Société de Réanimation de Langue Française (SRLF), with the participation of the French Language Group of Paediatric Intensive Care and Emergencies (GFRUP), the French Society of Emergency Medicine (SFMU), the French Society of Gastroenterology (SNFGE), and the French Society of Digestive Endoscopy (SFED). The recommendations cover five fields of application: management of gastrointestinal bleeding before endoscopic diagnosis, treatment of upper gastrointestinal bleeding unrelated to portal hypertension, treatment of upper gastrointestinal bleeding related to portal hypertension, management of presumed lower gastrointestinal bleeding, and prevention of upper gastrointestinal bleeding in intensive care.
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Affiliation(s)
- David Osman
- AP-HP, Hôpitaux universitaires Paris-Sud, Hôpital de Bicêtre, Service de réanimation médicale, Le Kremlin-Bicêtre, F-94270, France.
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Frandah W, Colmer-Hamood J, Nugent K, Raj R. Patterns of Use of Prophylaxis for Stress-Related Mucosal Disease in Patients Admitted to the Intensive Care Unit. J Intensive Care Med 2012; 29:96-103. [DOI: 10.1177/0885066612453542] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background: Morbidity associated with stress ulcer–related bleeding, the cost of medications, and the possible complications associated with stress ulcer prophylaxis are important considerations when prescribing prophylaxis. We prospectively studied the prescription patterns for stress ulcer prophylaxis in patients admitted to our ICU. Methods: We prospectively recorded the indications for stress ulcer prophylaxis and prescription patterns for use based on the American Society of Healthcare Pharmacists criteria and other indications for 99 new intensive care unit (ICU) admissions to a tertiary referral center. Results: In all 51 patients had no indication for stress ulcer prophylaxis, 32 had 1 indication, 14 had 2 indications, and 2 patients had 3 indications for receiving stress ulcer prophylaxis in the ICU. Eighty-two percent of patients without any indications received stress ulcer prophylaxis; 81% of patients with 1 indication, 79% of patients with 2 indication, and 50% of patients with 3 indications received stress ulcer prophylaxis. Overall, 53% of patients either received stress ulcer prophylaxis when none was indicated or did not receive stress ulcer prophylaxis when it was indicated. We also review the recent literature on stress-related mucosal disease and the use of prophylaxis for stress-related mucosal disease. Conclusions: Stress ulcer prophylaxis administration in this ICU is inconsistent and includes both underutilization and overutilization. Educating physicians and implementing hospital protocols could improve use patterns.
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Affiliation(s)
- Wesam Frandah
- Department of Internal Medicine , Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Jane Colmer-Hamood
- Department of Microbiology, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Kenneth Nugent
- Department of Internal Medicine , Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Rishi Raj
- Department of Internal Medicine , Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Prise en charge par le réanimateur des hémorragies digestives de l’adulte et de l’enfant. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-012-0489-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Hurt RT, Frazier TH, McClave SA, Crittenden NE, Kulisek C, Saad M, Franklin GA. Stress Prophylaxis in Intensive Care Unit Patients and the Role of Enteral Nutrition. JPEN J Parenter Enteral Nutr 2012; 36:721-31. [DOI: 10.1177/0148607112436978] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Ryan T. Hurt
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Thomas H. Frazier
- Department of Medicine, University of Louisville, Louisville, Kentucky
| | | | | | | | - Mohamed Saad
- Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Glen A. Franklin
- Department of Surgery, University of Louisville, Louisville, Kentucky
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VOORT PHJVANDER, HULST RWMVANDER, ZANDSTRA DF, ENDE AVANDER, GERAEDTS AAM, TYTGAT GNJ. Detection ofHelicobacter pyloriin mechanically ventilated patients: the LARA-13C-urea breath test and serology. ACTA ACUST UNITED AC 2011. [DOI: 10.3109/tcic.10.3.91.95] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Clinical trials conducted in the latter part of the past millennium suggested that bleeding from gastric stress ulceration was an important cause of morbidity and mortality in intensive care unit (ICU) patients and that treatment with acid-suppressive therapy reduced the risk of clinically significant bleeding. Stress ulcer prophylaxis therefore became regarded as the standard of care in all ICU patients. However, more recent clinical trials have demonstrated that the risk of clinically significant bleeding is extremely low (about 1%) and not altered by the use of acid-suppressive therapy. Furthermore, a critical review of the “historical” clinical trials, as well as the data from experimental and more recent clinical trials, suggests that enteral feeding (gastric) is at least as effective as acid-suppressive therapy in the prevention of gastric stress ulceration and is the prophylactic measure of choice in most ICU patients.
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Pang SH, Graham DY. A clinical guide to using intravenous proton-pump inhibitors in reflux and peptic ulcers. Therap Adv Gastroenterol 2010; 3:11-22. [PMID: 21180586 PMCID: PMC3002568 DOI: 10.1177/1756283x09352095] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Intravenous (IV) proton-pump inhibitors (PPIs) are potent gastric acid suppressing agents, and their use is popular in clinical practice. Both IV and oral PPIs have similarly short half-lives, and their effects on acid secretion are similar, thus their dosing and dosage intervals appear to be interchangeable. The possible exception is when sustained high pHs are required to promote clot stabilization in bleeding peptic ulcers. Continuous infusion appears to be the only form of administration that reliably achieves these high target pHs. IV PPI is indicated in the treatment of high-risk peptic ulcers, complicated gastroesophageal reflux, stress-induced ulcer prophylaxis, Zollinger-Ellison syndrome, and whenever it is impossible or impractical to give oral therapy. The widespread use of PPIs has been controversial. IV PPIs have been linked to the development of nosocomial pneumonia in the intensive care setting and to spontaneous bacterial peritonitis in cirrhotic patients. This review discusses the use of IV PPI in different clinical scenarios, its controversies, and issues of appropriate use.
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Affiliation(s)
- Sandy H. Pang
- Institute of Digestive Disease, Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - David Y. Graham
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA,
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Abstract
Increased knowledge of risk factors and improved ICU care has decreased the incidence of stress-related bleeding. Not all critically ill patients need prophylaxis for SRMD and withholding such prophylaxis in suitable low-risk candidates is a reasonable and cost-effective approach. Mechanical ventilation for more than 48 hours and coagulopathy are the main risk factors for stress-induced upper GI bleeding. Although intravenous H2RAs can prevent clinically important bleeding, their benefits seem to be limited by the rapid development of tolerance. The availability of intravenous formulations of PPIs makes it possible to critically compare their prophylactic efficacy and safety to different classes of acid-suppressive agents, such as H2RAs, in critically ill patients. The appropriate dose of PPI and the role of newer PPI formulations need to be further defined along with proposed guidelines for the use of intravenous and oral/enteral formulations of PPIs in patients at risk for stress-related mucosal damage.
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Affiliation(s)
- Tauseef Ali
- Section of Digestive Diseases and Nutrition, Department of Internal Medicine, University of Oklahoma Health Sciences Center, 1360 WP, 920 SL Young Boulevard, Oklahoma City, OK 73104, USA
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Robert R, Gissot V, Pierrot M, Laksiri L, Mercier E, Prat G, Villers D, Vincent JF, Hira M, Vignon P, Charlot P, Burucoa C. Helicobacter pylori infection is not associated with an increased hemorrhagic risk in patients in the intensive care unit. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006; 10:R77. [PMID: 16704741 PMCID: PMC1550927 DOI: 10.1186/cc4920] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/19/2005] [Revised: 04/11/2006] [Accepted: 04/18/2006] [Indexed: 02/08/2023]
Abstract
Introduction The potential role of Helicobacter pylori in acute stress ulcer in patients in an intensive care unit (ICU) is controversial. The aim of this study was to determine the frequency of H. pylori infection in ICU patients by antigen detection on rectal swabs, and to analyze the potential relationship between the presence of H. pylori and the risk of digestive gastrointestinal bleeding. Methods In this prospective, multicenter, epidemiological study, the inclusion criteria were as follows: patients admitted to the 12 participating ICU for at least two days, who were free of hemorrhagic shock and did not receive more than four units of red blood cells during the day before or the first 48 hours after admission to the ICU. Rectal swabs were obtained within the first 24 hours of admission to the ICU and were tested for H. pylori antigens with the ImmunoCard STAT! HpSA kit. The following events were analyzed according to H. pylori status: gastrointestinal bleeding, unexplained decline in hematocrit, and the number of red cell transfusions. Results The study involved 1,776 patients. Forty-nine patients (2.8%) had clinical evidence of upper digestive bleeding. Esophagogastroduodenoscopy was performed in 7.6% of patients. Five hundred patients (28.2%) required blood transfusion. H. pylori antigen was detected in 6.3% of patients (95% confidence interval 5.2 to 7.5). H. pylori antigen positivity was associated with female sex (p < 0.05) and with a higher Simplified Acute Physiology Score II (SAPS II; p < 0.05). H. pylori antigen status was not associated with the use of fiber-optic gastroscopy, the need for red cell transfusions, or the number of red cell units infused. Conclusion This large study reported a small percentage of H. pylori infection detected with rectal swab sampling in ICU patients and showed that the patients infected with H. pylori had no additional risk of gastrointestinal bleeding. Thus H. pylori does not seem to have a major role in the pathogenesis of acute stress ulcer in ICU patients.
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Affiliation(s)
- René Robert
- Réanimation Médicale, CHU Poitiers, 2 rue de la milèterie, BP 577 86021 Poitiers cedex France
| | - Valérie Gissot
- Réanimation Polyvalente, Hopital Girac 16140 Saint Michel France
| | - Marc Pierrot
- Réanimation Médicale, CHU Angers 4 rue Larrey 49100 Angers France
| | - Leila Laksiri
- Réanimation Chirurgicale, CHU Poitiers, 2 rue de la milèterie, BP 577, 86021 Poitiers cedex France
| | - Emmanuelle Mercier
- Réanimation Médicale, CHU Bretonneau, 2 Boulevard Tonnelé 37044 Tours, France
| | - Gwenael Prat
- Réanimation Médicale, CHU de la Cavale Blanche rue Tanguy Pringent 29200 Brest, France
| | - Daniel Villers
- Réanimation Médicale, CHU Nantes, 1 place Alexis Ricordeau 44093 Nantes cedex, France
| | - Jean-François Vincent
- Réanimation Polyvalente, Centre hospitalier de Saintes, 9 place du 11 novembre BP 326, 17108 Saintes cedex, France
| | - Michel Hira
- Réanimation Polyvalente Chateauroux, Centre hospitalier de Chateauroux 216 avenue de verdun 36000 Chateauroux, France
| | - Philippe Vignon
- Réanimation Polyvalente Limoges, CHU Dupuytren 2 avenue Martin Luther King 87042 Limoges cedex, France
| | - Patrick Charlot
- Réanimation Polyvalente Niort, 40 avenue du général de Gaulle 79000 Niort, France
| | - Christophe Burucoa
- Laboratoire de Microbiologie A EA 3807, CHU Poitiers, 2 rue de la milèterie, BP 577, 86021 Poitiers cedex France
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Maury E, Tankovic J, Ebel A, Offenstadt G. An observational study of upper gastrointestinal bleeding in intensive care units: is Helicobacter pylori the culprit? Crit Care Med 2005; 33:1513-8. [PMID: 16003056 DOI: 10.1097/01.ccm.0000168043.60624.3e] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Upper gastrointestinal bleeding (UGIB) related to stress ulcers was formerly a fearsome complication of intensive care. The incidence of this event has decreased over the years. However, the morbidity, mortality, and causes of UGIB, particularly the etiologic role of Helicobacter pylori infection, are still controversial. Therefore, we prospectively assessed the incidence of UGIB in the intensive care unit (ICU) and evaluated the role of H. pylori infection. DESIGN A prospective observational study followed by a case-control study. SETTING Seven ICUs in the Paris area, five of them located in teaching hospitals. PATIENTS All patients admitted consecutively to seven ICUs during a 1-year period were monitored for signs of clinically relevant UGIB. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Only cases of endoscopically confirmed UGIB were analyzed. Patients whose hemorrhage originated from the stomach and/or duodenum were tested for H. pylori infection, by means of serology, histologic examination, and stool antigen detection. The possible association between H. pylori and UGIB was examined in a case-control study. Twenty-nine of the 4,341 patients admitted to the seven ICUs during the study period had clinically relevant, endoscopically confirmed UGIB (incidence, 0.67%; 95% confidence interval, 0.56%-0.77%). Ulcers were most frequently observed endoscopically. Patients who bled had a higher Simplified Acute Physiology Score (SAPS II) at admission (mean +/- sd, 47 +/- 14 vs. 36 +/- 28; p < .001). Despite a higher in-ICU mortality rate among patients who bled (73% vs. 16%; p < .001), death was never due to bleeding. H. pylori infection was more frequent in patients who bled than in matched controls (36% vs. 16%; p = .04). CONCLUSIONS Clinically relevant, endoscopically confirmed UGIB is a rare event in the ICU setting and tends to occur in severely ill patients. H. pylori infection is more frequent in patients with gastroduodenal hemorrhage than in nonbleeding patients.
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Affiliation(s)
- Eric Maury
- Service de Réanimation Médicale, Unité Inserm U444, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
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Klebl FH, Bregenzer N, Schöfer L, Tamme W, Langgartner J, Schölmerich J, Messmann H. Comparison of inpatient and outpatient upper gastrointestinal haemorrhage. Int J Colorectal Dis 2005; 20:368-75. [PMID: 15551100 DOI: 10.1007/s00384-004-0642-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2004] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Inpatients developing upper gastrointestinal (GI) haemorrhage are at increased risk of death. This study was performed to elucidate differences in inpatients and outpatients. PATIENTS/METHODS Three hundred and sixty-two patients who needed esophagogastroduodenoscopy for upper GI bleeding were identified from endoscopy charts. Patients' characteristics, bleeding parameters, clinical presentation, pre-existing medication, and laboratory data were compared between patients who were admitted because of upper GI bleeding and patients who developed bleeding while in hospital for other reasons. RESULTS/FINDINGS Hospital mortality was 39.0% in inpatients vs. 11.1% in outpatients (p<0.01). Death due to bleeding was observed in 9.5% of inpatients vs. 2.5% of outpatients (p<0.01). Whereas peptic ulcer was the most common source of bleeding in both, variceal bleeding was the most common cause of death because of haemorrhage in both. Recurrent bleeding was associated with mortality in outpatients (p<0.001), but not in inpatients (p=0.11). Rates of bleeding recurrence and need for surgery was similar in both groups. Inpatients suffered more often from renal disease, pulmonary disease, diabetes mellitus, coagulopathy, or immunosuppression, and were treated more frequently with acetylsalicylic acid, glucocorticoids and heparin. The frequency of pre-existing disease was higher in inpatients. INTERPRETATION/CONCLUSION Higher mortality after GI bleeding in inpatients than in outpatients is due to a generally higher prevalence of co-morbidity rather than a single or a few risk factors.
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Affiliation(s)
- Frank H Klebl
- Department of Internal Medicine I, University of Regensburg, 93042 Regensburg, Germany.
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Klebl F, Bregenzer N, Schöfer L, Tamme W, Langgartner J, Schölmerich J, Messmann H. Risk factors for mortality in severe upper gastrointestinal bleeding. Int J Colorectal Dis 2005; 20:49-56. [PMID: 15322836 DOI: 10.1007/s00384-004-0624-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2004] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Factors related to mortality after upper gastrointestinal (GI) bleeding may differ in importance in high- and low-risk populations. This retrospective study was undertaken to define risk factors of mortality in patients needing endoscopy for upper gastrointestinal bleeding at a tertiary care centre. PATIENTS/METHODS Three hundred and sixty-two patients with upper gastrointestinal bleeding were identified from endoscopy charts. Patients' characteristics, bleeding parameters, clinical presentation, pre-existing medication and laboratory data were retrieved from hospital charts and patients who survived and those who died in hospital were compared. RESULTS/FINDINGS The mean Rockall score was 6.6+/-1.3 with 92.5% of patients belonging to a Rockall high-risk group. In hospital, mortality was 26.5%, with 6.4% of patients dying as a direct consequence of bleeding. Variceal bleeding was associated with a high risk of recurrent bleeding and death. Renal disease, liver disease, coagulopathy and immunosuppression were more frequently found in non-survivors than in survivors. Accordingly, serological tests of renal or liver function and coagulation were more disturbed in non-survivors. On average, heart rate was higher, and blood pressure and haemoglobin levels lower in non-survivors. Heparin, glucocorticoids, and anti-ulcer drugs were more frequently used in patients dying in hospital. By logistic regression analysis, in-patient status at the time of bleeding, renal disease and coagulopathy, as well as glucocorticoid use, were risk factors for hospital mortality. INTERPRETATION/CONCLUSION In tertiary care, a high mortality rate is observed in upper GI bleeding. Teams involved in treating such patients should be aware of the setting in which treatment is performed and its related risk factors.
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Affiliation(s)
- Frank Klebl
- Department of Internal Medicine I, University of Regensburg, 93042 Regensburg, Germany.
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Robertson MS, Clancy RL, Cade JF. Helicobacter pylori in intensive care: why we should be interested. Intensive Care Med 2003; 29:1881-8. [PMID: 14608460 DOI: 10.1007/s00134-003-1838-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2002] [Accepted: 05/05/2003] [Indexed: 12/20/2022]
Abstract
Helicobacter pylori is estimated to infect over 50% of the world's population, the majority of whom are asymptomatic. Although most research to date has focused on local gastroduodenal disease manifestations, the potential impact of H. pylori infection and the associated chronic active inflammation on systemic disease processes is now being explored. This review addresses three aspects of emerging importance regarding H. pylori in intensive care medicine: acute gastric stress ulceration, nosocomial infection, and the potential modulatory effect on the systemic stress response. The role of H. pylori in acute stress ulceration remains uncertain, but it is unlikely to have the same major aetiological role as in peptic ulcer disease. The pathogenesis of both acute stress ulceration and H. pylori gastritis suggest overlapping mechanisms of gastric mucosal damage and H. pylori may augment stress ulceration incidence and severity. Nosocomial infection of both staff and patients with H. pylori has been suggested by serological studies, and increased H. pylori infection has been reported in intensive care staff. This has significant short- and long-term health implications and also raises questions regarding the efficacy and implementation of routine infection control precautions in intensive care. Finally, H. pylori infection has been linked with the pathogenesis of many extra-intestinal diseases, but the evidence is weak and the relationship between H. pylori and systemic diseases remains controversial. However, the potential for H. pylori to modulate systemic disease processes, particularly the systemic stress response in critical illness, is both theoretically plausible and therapeutically tantalising and requires further investigation.
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Affiliation(s)
- Megan S Robertson
- Intensive Care Unit, The Royal Melbourne Hospital, 3050, Parkville, VIC, Australia.
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Abstract
Stress-related mucosal disease is common in critically ill patients and can result in significant morbidity. The pathophysiology of this condition is multifactorial but mucosal ischaemia and gastric acid have pivotal roles. The major risk factors for developing stress-related mucosal bleeding are prolonged mechanical ventilation and coagulopathy. The mainstay of clinical management is prevention with acid-suppressing medications and cytoprotective agents. This chapter discusses medications used to prevent this condition and suggests an approach for management. Recent developments in gastroenterology include the development and use of proton pump inhibitors and the discovery of the association Helicobacter pylori with gastritis. The role of each of these in stress-related mucosal disease is discussed. Finally, an approach to the bleeding critically ill patient is presented.
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Affiliation(s)
- Donald R Duerksen
- Division of Gastroenterology, Department of Medicine, St Bonfaice Hospital, C5 120 409 Tache Avenue, Winnipeg, Man., Canada R2H 2A6.
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Conrad SA. Acute upper gastrointestinal bleeding in critically ill patients: causes and treatment modalities. Crit Care Med 2002; 30:S365-8. [PMID: 12072663 DOI: 10.1097/00003246-200206001-00006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Upper gastrointestinal bleeding from peptic ulcers or other nonvariceal causes generally stops spontaneously; if it fails to do so, aggressive management is required. Such measures also are necessary for patients at high risk for rebleeding. Endoscopic therapy achieves hemostasis in >90% of bleeding patients and reduces mortality. After successful hemostasis of the initial bleeding episode, the primary concern becomes the prevention of rebleeding, which occurs in up to 20% of patients. Acid suppression with histamine-2-receptor antagonists has been widely used for many years to prevent recurrent bleeding. However, in acutely bleeding patients, these agents have not been shown to reduce the number of episodes of further bleeding or rebleeding or to reduce the need for transfusions or surgery. Omeprazole, an intravenous proton pump inhibitor, significantly reduced the rate of rebleeding in a recent placebo-controlled trial in which only patients with endoscopic confirmation of successful hemostasis were enrolled. Although this drug does not seem to reduce the need for surgical intervention or to decrease mortality, the trial does indicate the promise of intravenous proton pump inhibitors in reducing upper gastrointestinal bleeding. Evidence from additional well-controlled trials is needed to confirm this finding. The use of proton pump inhibitors in this setting also may have a positive economic impact, and a decrease in the percentage of patients who experience rebleeding will eliminate the cost of further management strategies in those cases.
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Affiliation(s)
- Steven A Conrad
- Department of Medicine and Emergency Medicine, LSU Health Sciences Center, Shreveport, LA 71130-3932, USA.
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Trautwein C, Manns MP, Böker KH. [Therapy of acute liver failure]. KONGRESSBAND. DEUTSCHE GESELLSCHAFT FUR CHIRURGIE. KONGRESS 2002; 118:238-47. [PMID: 11824254 DOI: 10.1007/978-3-642-56458-1_75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- C Trautwein
- Abteilung Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover
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van der Voort PH, van der Hulst RW, Zandstra DF, Geraedts AA, van der Ende A, Tytgat GN. Suppression of Helicobacter pylori infection during intensive care stay: related to stress ulcer bleeding incidence? J Crit Care 2001; 16:182-7. [PMID: 11815904 DOI: 10.1053/jcrc.2001.30164] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To assess the prevalence of active Helicobacter pylori infection in patients admitted to the intensive care unit, to determine the effect of selective gut decontamination on the persistence of this organism, and to explore the possible relationship between H. pylori infection and stress ulcer bleeding incidence. MATERIALS AND METHODS We determined in a prospective observational study of 300 consecutive, mechanically ventilated patients the activity of H. pylori infection and the incidence of stress ulcer-related upper gastrointestinal bleeding over time. H. pylori infection was detected by Laser-Assisted Ratio Analyzer (LARA)- (13)C-urea breath test (Alimenterics, Inc., NJ) and serology. Stress ulcer prophylaxis was not prescribed. Endoscopy was performed in cases of upper gastrointestinal bleeding. RESULTS The prevalence of active H. pylori infection on admission was 38% as detected by urea breath test, and declined to 8% on the third day, and to 0% on the seventh day after admission as a result of antibiotic treatment. Stress ulcer-related upper gastrointestinal bleeding occurred in 1.0% (3 of 300) of the patients; none were infected with H. pylori on admission or at the time of bleeding. CONCLUSIONS H. pylori infection monitored by LARA- (13)C-urea breath test was rapidly suppressed during intensive care treatment, which can be explained by the routine use of antibiotics for gut decontamination.The low incidence of stress ulcer-related bleeding might be related to the prevention of H. pylori-associated stress lesions by effective suppression of this microorganism, but further studies are warranted to test this hypothesis.
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Affiliation(s)
- P H van der Voort
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
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Affiliation(s)
- K H Boeker
- Department of Gastroenterology and Hepatology, Medizinische Hochschule, Hannover, Germany
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Wassef W, Obando J, Sharma A. Upper Gastrointestinal Bleeding of Nonvariceal Origin in the ICU Setting. J Intensive Care Med 2001. [DOI: 10.1046/j.1525-1489.2001.00105.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Wassef W, Obando J, Sharma A. Upper Gastrointestinal Bleeding of Nonvariceal Origin in the ICU Setting. J Intensive Care Med 2001. [DOI: 10.1177/088506660101600301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Upper gastrointestinal bleeding (UGI) is a common medical emergency in the intensive care unit (ICU). Although it can be caused by a number of gastrointestinal disorders, its management usually follows a few simple management rules. Prior to endoscopy, the key to management is to resuscitate the patient, to determine the need for airway protection, and to assess the need for transfusions according to the American Society of Gastrointestinal Endoscopy guidelines. During endoscopy, the key to management is to recognize the cause of the bleeding and to achieve hemostasis. Following endoscopy, the key to management is to determine the need for medical therapy and to determine a proper disposition for the patient given his potential risk for rebleeding. Stress-related erosions syndrome (SRES) is a disease that usually develops in the ICU setting and is known to be associated with a high degree of morbidity and mortality. Although it is approached in the same fashion as other causes of UGI bleeding, patients tend to do better if they are recognized early and treated prophylactically. Criteria for proper patient selection and the recommended prophylactic therapy are reviewed.
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Affiliation(s)
- Wahid Wassef
- Division of Digestive Disease and Nutrition, UMass Memorial Health Care, University of Massachusetts Medical School, Worcester, MA
| | - Jorge Obando
- Division of Digestive Disease and Nutrition, UMass Memorial Health Care, University of Massachusetts Medical School, Worcester, MA
| | - Ashish Sharma
- Division of Digestive Disease and Nutrition, UMass Memorial Health Care, University of Massachusetts Medical School, Worcester, MA
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van der Voort PH, Zandstra DF. Pathogenesis, risk factors, and incidence of upper gastrointestinal bleeding after cardiac surgery: Is specific prophylaxis in routine bypass procedures needed? J Cardiothorac Vasc Anesth 2000. [DOI: 10.1053/cr.2000.5849] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Miskovitz P. Upper gastrointestinal hemorrhage in the inpatient hospital setting: a different beast? Crit Care Med 2000; 28:261-2. [PMID: 10667540 DOI: 10.1097/00003246-200001000-00050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Halm U, Halm F, Thein D, Mohr FW, Mössner J. Helicobacter pylori infection: a risk factor for upper gastrointestinal bleeding after cardiac surgery? Crit Care Med 2000; 28:110-3. [PMID: 10667508 DOI: 10.1097/00003246-200001000-00018] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To determine the prevalence of Helicobacter pylori (H. pylori) in critically ill patients who develop upper gastrointestinal bleeding after cardiac surgery in relation to other risk factors. DESIGN Prospective, single center, cohort study. SETTING Surgical intensive care unit in a university hospital. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Over a 1-yr period, all consecutive patients with upper gastrointestinal hemorrhage from the stomach or duodenum were studied for H. pylori infection by serology. Additionally, the need for mechanical ventilation over 48 hrs, the duration cardiopulmonary bypass, and the aortic cross-clamp time were analyzed. For control, 229 patients with no evidence of gastrointestinal hemorrhage after cardiac surgery were studied. All patients received stress ulcer prophylaxis with ranitidine. Operations were performed on 2,956 patients during the study period. The incidence of upper gastrointestinal bleeding was 0.9%. Twenty (77%) of the 26 patients with upper gastrointestinal bleeding and 145 (63%) patients of the control group had serologic evidence for H. pylori infection (odds ratio, 1.9; 95% confidence interval 0.7-5.0; p = .2). Patients who required prolonged mechanical ventilation had a significantly greater risk for upper gastrointestinal bleeding (odds ratio, 22.1; 95% confidence interval 8.6-56.7; p<.001). Patients with upper gastrointestinal bleeding also had a significantly longer duration of cardiopulmonary bypass and aortic cross-clamp time (p<.001) CONCLUSIONS H. pylori is not associated with upper gastrointestinal bleeding in critically ill patients who receive stress ulcer prophylaxis, whereas patients who require prolonged mechanical ventilation are at high risk. A prophylactic eradication of H. pylori is not justified.
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Affiliation(s)
- U Halm
- Department of Internal Medicine II, University of Leipzig, Germany
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Marik PE. Analytic Reviews : Stress Ulcer Prophylaxis: A Practical Approach. J Intensive Care Med 1999. [DOI: 10.1177/088506669901400101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Riester KA, Peduzzi P, Holford TR, Ellison RT, Donta ST. Statistical evaluation of the role of Helicobacter pylori in stress gastritis: applications of splines and bootstrapping to the logistic model. J Clin Epidemiol 1997; 50:1273-9. [PMID: 9393383 DOI: 10.1016/s0895-4356(97)00180-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Stress gastritis is a serious problem in the intensive care unit population. The recent discovery of the causal nature of Helicobacter pylori (H. pylori) in the development of gastric ulcers led us to examine its relationship with stress gastritis. We investigated this relationship in 874 veterans admitted to intensive care units who were tested for the presence of H. pylori and followed for 6 weeks for the development of stress gastritis. We fit spline models to assess functional relationships and used the logistic model to determine the association between H. pylori and stress gastritis. The predictive ability of the model was assessed with receiver operating characteristic (ROC) curve analysis and validated with the bootstrapping technique. Increased anti-H. pylori immunoglobulin A concentrations were found to be an important predictor of stress gastritis independent of other known risk factors.
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Affiliation(s)
- K A Riester
- Department of Veterans Affairs Cooperative Studies Program Coordinating Center, West Haven, Connecticut, USA
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