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Pasha SB, Tarar ZI, Chela H, McDermott A, Ihnat J, Matteson-Kome ML, Ghouri YA, Bechtold ML. Should Prophylactic Endotracheal Intubation Be Performed in Upper Gastrointestinal Bleeding? Cureus 2024; 16:e64567. [PMID: 39144893 PMCID: PMC11323713 DOI: 10.7759/cureus.64567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2024] [Indexed: 08/16/2024] Open
Abstract
No consensus exists on the standard of intraoperative airway management approach to prevent endoscopy complications in acute gastrointestinal (GI) bleeding. Eight years after our initial meta-analysis, we reassessed the effect of prophylactic endotracheal intubation in acute GI bleeding in hospitalized patients. Multiple databases were reviewed in 2024, identifying 10 studies that compared prophylactic endotracheal intubation (PEI) versus no intubation in acute upper GI bleeding in hospitalized patients. Outcomes of interest included pneumonia, length of hospital stay, aspiration, and mortality. The odds ratio (OR) or mean difference (MD) using the random effects model was calculated for each outcome. In total, 11 studies (10 retrospective, one prospective) were included in the meta-analysis (n = 7,332). PEI demonstrated statistically significant higher odds of pneumonia (OR = 5.83; 95% confidence interval (CI) = 3.15-10.79; p < 0.01) and longer length of stays (MD = 0.84; 95% CI = 0.12-1.56; p = 0.02). However, mortality (OR = 1.68; 95% CI = 0.78-3.64; p = 0.19) and aspiration (OR = 2.79; 95% CI = 0.89-8.7; p = 0.08) were not statistically significant. PEI before esophagogastroduodenoscopy for hospitalized upper GI bleeding patients is associated with an increased incidence of pneumonia within 48 hours and prolonged hospitalization but no statistically significant increased risk of mortality or aspiration.
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Affiliation(s)
- Syed Bilal Pasha
- Gastroenterology and Hepatology, University of Missouri, Columbia, USA
| | | | - Harleen Chela
- Internal Medicine, University of Missouri, Columbia, USA
| | | | - Jocelyn Ihnat
- Internal Medicine, University of Missouri, Columbia, USA
| | | | - Yezaz A Ghouri
- Internal Medicine/Gastroenterology and Hepatology, University of Missouri School of Medicine, Columbia, USA
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Lin Y, Song F, Zeng W, Han Y, Chen X, Chen X, Ouyang Y, Zhou X, Zou G, Wang R, Li H, Li X. Cardiopulmonary prognosis of prophylactic endotracheal intubation in patients with upper gastrointestinal bleeding undergoing endoscopy. World J Emerg Med 2023; 14:372-379. [PMID: 37908798 PMCID: PMC10613797 DOI: 10.5847/wjem.j.1920-8642.2023.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/20/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND It is controversial whether prophylactic endotracheal intubation (PEI) protects the airway before endoscopy in critically ill patients with upper gastrointestinal bleeding (UGIB). The study aimed to explore the predictive value of PEI for cardiopulmonary outcomes and identify high-risk patients with UGIB undergoing endoscopy. METHODS Patients undergoing endoscopy for UGIB were retrospectively enrolled in the eICU Collaborative Research Database (eICU-CRD). The composite cardiopulmonary outcomes included aspiration, pneumonia, pulmonary edema, shock or hypotension, cardiac arrest, myocardial infarction, and arrhythmia. The incidence of cardiopulmonary outcomes within 48 h after endoscopy was compared between the PEI and non-PEI groups. Logistic regression analyses and propensity score matching analyses were performed to estimate effects of PEI on cardiopulmonary outcomes. Moreover, restricted cubic spline plots were used to assess for any threshold effects in the association between baseline variables and risk of cardiopulmonary outcomes (yes/no) in the PEI group. RESULTS A total of 946 patients were divided into the PEI group (108/946, 11.4%) and the non-PEI group (838/946, 88.6%). After propensity score matching, the PEI group (n=50) had a higher incidence of cardiopulmonary outcomes (58.0% vs. 30.3%, P=0.001). PEI was a risk factor for cardiopulmonary outcomes after adjusting for confounders (odds ratio [OR] 3.176, 95% confidence interval [95% CI] 1.567-6.438, P=0.001). The subgroup analysis indicated the similar results. A shock index >0.77 was a predictor for cardiopulmonary outcomes in patients undergoing PEI (P=0.015). The probability of cardiopulmonary outcomes in the PEI group depended on the Charlson Comorbidity Index (OR 1.465, 95% CI 1.079-1.989, P=0.014) and shock index >0.77 (compared with shock index ≤0.77 [OR 2.981, 95% CI 1.186-7.492, P=0.020, AUC=0.764]). CONCLUSION PEI may be associated with cardiopulmonary outcomes in elderly and critically ill patients with UGIB undergoing endoscopy. Furthermore, a shock index greater than 0.77 could be used as a predictor of a worse prognosis in patients undergoing PEI.
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Affiliation(s)
- Yufang Lin
- School of Biology and Biological Engineering, South China University of Technology, Guangzhou 510006, China
- Department of Emergency Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Fei’er Song
- Department of Emergency Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Weiyue Zeng
- Department of Emergency Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Yichi Han
- Department of Emergency Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xiujuan Chen
- Medical Big Data Center, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xuanhui Chen
- Medical Big Data Center, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Yu Ouyang
- Department of Emergency Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xueke Zhou
- Department of Emergency Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
- School of Medicine, South China University of Technology, Guangzhou 510006, China
| | - Guoxiang Zou
- Department of Emergency Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Ruirui Wang
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510100, China
| | - Huixian Li
- Medical Big Data Center, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xin Li
- School of Biology and Biological Engineering, South China University of Technology, Guangzhou 510006, China
- Department of Emergency Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
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3
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Gralnek IM, Camus Duboc M, Garcia-Pagan JC, Fuccio L, Karstensen JG, Hucl T, Jovanovic I, Awadie H, Hernandez-Gea V, Tantau M, Ebigbo A, Ibrahim M, Vlachogiannakos J, Burgmans MC, Rosasco R, Triantafyllou K. Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54:1094-1120. [PMID: 36174643 DOI: 10.1055/a-1939-4887] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
1: ESGE recommends that patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [BMI < 30 kg/m2] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] > 10 mmHg and/or liver stiffness by transient elastography > 25 kPa) should receive, if no contraindications, nonselective beta blocker (NSBB) therapy (preferably carvedilol) to prevent the development of variceal bleeding.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in those patients unable to receive NSBB therapy with a screening upper gastrointestinal (GI) endoscopy that demonstrates high risk esophageal varices, endoscopic band ligation (EBL) is the endoscopic prophylactic treatment of choice. EBL should be repeated every 2-4 weeks until variceal eradication is achieved. Thereafter, surveillance EGD should be performed every 3-6 months in the first year following eradication.Strong recommendation, moderate quality evidence. 3: ESGE recommends, in hemodynamically stable patients with acute upper GI hemorrhage (UGIH) and no history of cardiovascular disease, a restrictive red blood cell (RBC) transfusion strategy, with a hemoglobin threshold of ≤ 70 g/L prompting RBC transfusion. A post-transfusion target hemoglobin of 70-90 g/L is desired.Strong recommendation, moderate quality evidence. 4 : ESGE recommends that patients with ACLD presenting with suspected acute variceal bleeding be risk stratified according to the Child-Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper GI endoscopy.Strong recommendation, high quality of evidence. 5 : ESGE recommends the vasoactive agents terlipressin, octreotide, or somatostatin be initiated at the time of presentation in patients with suspected acute variceal bleeding and be continued for a duration of up to 5 days.Strong recommendation, high quality evidence. 6 : ESGE recommends antibiotic prophylaxis using ceftriaxone 1 g/day for up to 7 days for all patients with ACLD presenting with acute variceal hemorrhage, or in accordance with local antibiotic resistance and patient allergies.Strong recommendation, high quality evidence. 7 : ESGE recommends, in the absence of contraindications, intravenous erythromycin 250 mg be given 30-120 minutes prior to upper GI endoscopy in patients with suspected acute variceal hemorrhage.Strong recommendation, high quality evidence. 8 : ESGE recommends that, in patients with suspected variceal hemorrhage, endoscopic evaluation should take place within 12 hours from the time of patient presentation provided the patient has been hemodynamically resuscitated.Strong recommendation, moderate quality evidence. 9 : ESGE recommends EBL for the treatment of acute esophageal variceal hemorrhage (EVH).Strong recommendation, high quality evidence. 10 : ESGE recommends that, in patients at high risk for recurrent esophageal variceal bleeding following successful endoscopic hemostasis (Child-Pugh C ≤ 13 or Child-Pugh B > 7 with active EVH at the time of endoscopy despite vasoactive agents, or HVPG > 20 mmHg), pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours (preferably within 24 hours) must be considered.Strong recommendation, high quality evidence. 11 : ESGE recommends that, for persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy, urgent rescue TIPS should be considered (where available).Strong recommendation, moderate quality evidence. 12 : ESGE recommends endoscopic cyanoacrylate injection for acute gastric (cardiofundal) variceal (GOV2, IGV1) hemorrhage.Strong recommendation, high quality evidence. 13: ESGE recommends endoscopic cyanoacrylate injection or EBL in patients with GOV1-specific bleeding.Strong recommendations, moderate quality evidence. 14: ESGE suggests urgent rescue TIPS or balloon-occluded retrograde transvenous obliteration (BRTO) for gastric variceal bleeding when there is a failure of endoscopic hemostasis or early recurrent bleeding.Weak recommendation, low quality evidence. 15: ESGE recommends that patients who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis).Strong recommendation, moderate quality evidence. 16: ESGE recommends the use of NSBBs (propranolol or carvedilol) in combination with endoscopic therapy for secondary prophylaxis in EVH in patients with ACLD.Strong recommendation, high quality evidence.
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Affiliation(s)
- Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa, Israel
| | - Marine Camus Duboc
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA) & Assistance Publique-Hôpitaux de Paris (AP-HP), Endoscopic Center, Saint Antoine Hospital, Paris, France
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, IRCSS-S. Orsola-Malpighi, Hospital, Bologna, Italy
| | - John Gásdal Karstensen
- Gastroenterology Unit, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tomas Hucl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ivan Jovanovic
- Euromedik Health Care System, Visegradska General Hospital, Belgrade, Serbia
| | - Halim Awadie
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Marcel Tantau
- University of Medicine and Pharmacy 'Iuliu Hatieganu' Cluj-Napoca, Romania
| | - Alanna Ebigbo
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | | | - Jiannis Vlachogiannakos
- Academic Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Marc C Burgmans
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
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Carballo Álvarez F, Albillos Martínez A, Llamas Silero P, Orive Calzada A, Redondo-Cerezo E, Rodríguez de Santiago E, Crespo García J. Consensus document of the Sociedad Española de Patología Digestiva on massive nonvariceal gastrointestinal bleeding and direct-acting oral anticoagulants. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2022; 114:375-389. [DOI: 10.17235/reed.2022.8920/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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5
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Martínez J, Hernández-Gea V, Rodríguez-de-Santiago E, Téllez L, Procopet B, Giráldez Á, Amitrano L, Villanueva C, Thabut D, Ibañez-Samaniego L, Silva-Junior G, Genescà J, Bureau C, Trebicka J, Bañares R, Krag A, Llop E, Laleman W, Palazon JM, Castellote J, Rodrigues S, Gluud LL, Noronha-Ferreira C, Cañete N, Rodríguez M, Ferlitsch A, Schwarzer R, Mundi JL, Gronbaek H, Hernández-Guerra M, Sassatelli R, Dell'Era A, Senzolo M, Abraldes JG, Romero-Gomez M, Zipprich A, Casas M, Masnou H, Primignani M, Nevens F, Calleja JL, Jansen C, Robic MA, Conejo I, Catalina MV, Rudler M, Alvarado E, Perez-Campuzano V, Guardascione MA, Fischer P, Bosch J, García-Pagán JC, Albillos A. Bacterial infections in patients with acute variceal bleeding in the era of antibiotic prophylaxis. J Hepatol 2021; 75:342-350. [PMID: 33845059 DOI: 10.1016/j.jhep.2021.03.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 03/23/2021] [Accepted: 03/25/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Antibiotic prophylaxis reduces the risk of infection and mortality in patients with cirrhosis and acute variceal bleeding (AVB). This study examines the incidence of, and risk factors for, bacterial infections during hospitalization in patients with AVB on antibiotic prophylaxis. METHODS A post hoc analysis was performed using the database of an international, multicenter, observational study designed to examine the role of pre-emptive transjugular intrahepatic portosystemic shunts in patients with cirrhosis and AVB. Data were collected on patients with cirrhosis hospitalized for AVB (n = 2,138) from a prospective cohort (October 2013-May 2015) at 34 referral centers, and a retrospective cohort (October 2011-September 2013) at 19 of these centers. The primary outcome was incidence of bacterial infection during hospitalization. RESULTS A total of 1,656 patients out of 1,770 (93.6%) received antibiotic prophylaxis; third-generation cephalosporins (76.2%) and quinolones (19.0%) were used most frequently. Of the patients on antibiotic prophylaxis, 320 patients developed bacterial infection during hospitalization. Respiratory infection accounted for 43.6% of infections and for 49.7% of infected patients, and occurred early after admission (median 3 days, IQR 1-6). On multivariate analysis, respiratory infection was independently associated with Child-Pugh C (odds ratio [OR] 3.1; 95% CI 1.4-6.7), grade III-IV encephalopathy (OR 2.8; 95% CI 1.8-4.4), orotracheal intubation for endoscopy (OR 2.6; 95% CI 1.8-3.8), nasogastric tube placement (OR 1.7; 95% CI 1.2-2.4) or esophageal balloon tamponade (OR 2.4; 95% CI 1.2-4.9). CONCLUSION Bacterial infections develop in almost one-fifth of patients with AVB despite antibiotic prophylaxis. Respiratory infection is the most frequent, is an early event after admission, and is associated with advanced liver failure, severe hepatic encephalopathy and use of nasogastric tube, orotracheal intubation for endoscopy or esophageal balloon tamponade. LAY SUMMARY Bacterial infections develop during hospitalization in close to 20% of patients with acute variceal bleeding despite antibiotic prophylaxis. Respiratory bacterial infections are the most frequent and occur early after admission. Respiratory infection is associated with advanced liver disease, severe hepatic encephalopathy and a need for a nasogastric tube, orotracheal intubation for endoscopy or esophageal balloon tamponade.
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Affiliation(s)
- Javier Martínez
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain; Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Virginia Hernández-Gea
- Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Enrique Rodríguez-de-Santiago
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain; Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Luis Téllez
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain; Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Bogdan Procopet
- Regional Institute of Gastroenterology and Hepatology "Octavian Fodor", Hepatology Department and "Iuliu Hatieganu" University of Medicine and Pharmacy, 3rd Medical Clinic, Cluj-Napoca, Romania
| | - Álvaro Giráldez
- Unit for the Clinical Management of Digestive Diseases, Virgen del Rocío University Hospital, Instituto de Biomedicina de Sevilla (IBIS), Liver Diseases, Seville, Spain
| | - Lucio Amitrano
- Gastroenterology Unit, Ospedale A Cardarelli, Naples, Italy
| | - Candid Villanueva
- Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Department of Gastroenterology and Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona, Spain
| | - Dominique Thabut
- Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Paris, France; Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Luis Ibañez-Samaniego
- Servicio de Medicina de Aparato Digestivo Gregorio Marañón, Hospital General Universitario Gregorio Marañón, CIBERehd, Madrid, Spain
| | - Gilberto Silva-Junior
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Joan Genescà
- Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona and CIBERehd, Barcelona, Spain
| | - Christophe Bureau
- Department of Hepato-Gastroenterology, Purpan Hospital, CHU Toulouse, INSERM U858, University of Toulouse, Toulouse, France
| | - Jonel Trebicka
- Department of Internal Medicine I, Goethe University Frankfurt, Frankfurt, Germany; European Foundation for the Study of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Rafael Bañares
- Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Servicio de Medicina de Aparato Digestivo Gregorio Marañón, Hospital General Universitario Gregorio Marañón, CIBERehd, Madrid, Spain
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Elba Llop
- Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Liver Unit, Hospital Universitario Puerta de Hierro. Universidad Autónoma de Madrid, CIBERehd, Madrid, Spain
| | - Wim Laleman
- Department Gastroenterology and Hepatology. Division of Liver and Biliopancreatic Disorders, University Hospitals Leuven - KU Leuven, Leuven, Belgium
| | | | - Jose Castellote
- Gastroenterology Department, Hepatology Unit, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, Barcelona, Spain
| | - Susana Rodrigues
- Gastroenterology and Hepatology Department, Centro Hospitalar São João, Porto, Portugal
| | - Lise L Gluud
- Gastro Unit, Medical Division, University Hospital of Hvidovre, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Carlos Noronha-Ferreira
- Serviço de Gastroenterología e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Nuria Cañete
- Liver Section, Gastroenterology Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manuel Rodríguez
- Department of Gastroenterology, Hospital Central de Asturias, Oviedo, Spain
| | - Arnulf Ferlitsch
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Remy Schwarzer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Jose Luis Mundi
- Department of Gastroenterology, University Hospital San Cecilio, Granada, Spain
| | - Henning Gronbaek
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Manuel Hernández-Guerra
- Gastroenterology Department, University Hospital of the Canary Islands, La Laguna, Tenerife, Spain
| | - Romano Sassatelli
- Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy
| | - Alessandra Dell'Era
- Gastroenterology Unit, ASST Fatebenefratelli Sacco, Department of Clinical and Biomedical Sciences 'Luigi Sacco', University of Milan, Milan, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Juan G Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
| | - Manuel Romero-Gomez
- Unidad de Hepatología, Hospital Universitario de Valme, CIBERehd, Sevilla, Spain
| | - Alexander Zipprich
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Meritxell Casas
- Hepatology Unit, Digestive Disease Department Hospital de Sabadell, Universitat Autónoma de Barcelona, Sabadell, Spain
| | - Helena Masnou
- Hospital Universitari Germans Trias i Pujol, Universitat Autònoma Barcelona, Badalona, Spain
| | - Massimo Primignani
- Division of Gastroenterology and Hepatology, IRCCSCa'Granda Maggiore Hospital Foundation, University of Milan, Milan, Italy
| | - Frederik Nevens
- Department Gastroenterology and Hepatology. Division of Liver and Biliopancreatic Disorders, University Hospitals Leuven - KU Leuven, Leuven, Belgium
| | - Jose Luis Calleja
- Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Liver Unit, Hospital Universitario Puerta de Hierro. Universidad Autónoma de Madrid, CIBERehd, Madrid, Spain
| | - Christian Jansen
- Department of Internal Medicine I, Universitiy of Bonn, Bonn, Germany
| | - Marie Angèle Robic
- Department of Hepato-Gastroenterology, Purpan Hospital, CHU Toulouse, INSERM U858, University of Toulouse, Toulouse, France
| | - Irene Conejo
- Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona and CIBERehd, Barcelona, Spain
| | - Maria Vega Catalina
- Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Servicio de Medicina de Aparato Digestivo Gregorio Marañón, Hospital General Universitario Gregorio Marañón, CIBERehd, Madrid, Spain
| | - Marika Rudler
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona, Spain; Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Edilmar Alvarado
- Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Department of Gastroenterology and Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona, Spain
| | - Valeria Perez-Campuzano
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | | | - Petra Fischer
- Regional Institute of Gastroenterology and Hepatology "Octavian Fodor", Hepatology Department and "Iuliu Hatieganu" University of Medicine and Pharmacy, 3rd Medical Clinic, Cluj-Napoca, Romania
| | - Jaime Bosch
- Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain; Department of Biomedical Research, Bern University, Hepatology, Inselspital, Bern, Switzerland
| | - Juan Carlos García-Pagán
- Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Agustín Albillos
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain; Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.
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6
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Chaudhuri D, Bishay K, Tandon P, Trivedi V, James PD, Kelly EM, Thavorn K, Kyeremanteng K. Prophylactic endotracheal intubation in critically ill patients with upper gastrointestinal bleed: A systematic review and meta-analysis. JGH OPEN 2019; 4:22-28. [PMID: 32055693 PMCID: PMC7008165 DOI: 10.1002/jgh3.12195] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 04/23/2019] [Indexed: 12/12/2022]
Abstract
Background and Aim Prophylactic endotracheal intubation for airway protection prior to endoscopy for the management of severe upper gastrointestinal bleeding (UGIB) is controversial. The aim of this meta‐analysis is to examine the clinical outcomes and costs related to prophylactic endotracheal intubation compared to no intubation in UGIB. Methods EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials were used to identify studies through June 2017. Data regarding mortality, total hospital and intensive care unit length of stay (LOS), pneumonia, and cardiovascular events were collected. The DerSimonian‐Laird random effects models were used to calculate the inverse variance‐based weighted, pooled treatment effect across studies. Results Seven studies (five manuscripts and two abstracts) were identified (5662 total patients). Prophylactic intubation conferred an increased risk of death (odds ratio [OR], 2.59, 95% confidence interval [CI]: 1.01–6.64), hospital LOS (mean difference, 0.96 days, 95% CI: 0.26–1.67), and pneumonia (OR 6.58, 95% CI: 4.91–8.81]) compared to endoscopy without intubation. The LOS‐related cost was greater when prophylactic intubation was performed ($9020 per patient, 95% CI: $6962–10 609) compared to when it was not performed ($7510 per patient, 95% CI: $6486–8432). There was no difference in risk of cardiovascular events after sensitivity analysis. Conclusion Prophylactic intubation in severe UGIB is associated with a greater risk of pneumonia, LOS, death, and cost compared to endoscopy without intubation. Randomized trials examining this issue are warranted.
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Affiliation(s)
- Dipayan Chaudhuri
- Department of Critical Care McMaster University Hamilton Ontario Canada
| | - Kirles Bishay
- Department of Gastroenterology University of Toronto Toronto Ontario Canada
| | - Parul Tandon
- Department of Gastroenterology University of Toronto Toronto Ontario Canada
| | - Vatsal Trivedi
- Department of Anesthesiology and Pain Medicine The Ottawa Hospital, University of Ottawa Ottawa Ontario Canada
| | - Paul D James
- Department of Gastroenterology University of Toronto Toronto Ontario Canada
| | - Erin M Kelly
- Department of Medicine The Ottawa Hospital, University of Ottawa Ottawa Ontario Canada.,Ottawa Hospital Research Institute The Ottawa Hospital Ottawa Ontario Canada
| | - Kednapa Thavorn
- School of Epidemiology, Public Health and Preventative Medicine, Faculty of Medicine University of Ottawa Ottawa Ontario Canada.,Division of Palliative Care The Ottawa Hospital, University of Ottawa Ottawa Ontario Canada
| | - Kwadwo Kyeremanteng
- Department of Medicine The Ottawa Hospital, University of Ottawa Ottawa Ontario Canada.,Ottawa Hospital Research Institute The Ottawa Hospital Ottawa Ontario Canada.,Division of Critical Care The Ottawa Hospital, University of Ottawa Ottawa Ontario Canada.,Institute du Savoir Montfort Ottawa Ontario Canada
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7
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Alshamsi F, Jaeschke R, Baw B, Alhazzani W. Prophylactic Endotracheal Intubation in Patients with Upper Gastrointestinal Bleeding Undergoing Endoscopy: A Systematic Review and Meta-analysis. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2017; 5:201-209. [PMID: 30787790 PMCID: PMC6298294 DOI: 10.4103/sjmms.sjmms_95_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: Patients with upper gastrointestinal bleeding (UGIB) often require urgent or emergent esophagogastroduodenoscopy (EGD) and are at risk of complications such as aspiration of gastric content or blood. The role of prophylactic endotracheal intubation (PEI) in the absence of usual respiratory status-related indications is not well established. Methods: We searched Medline, EMBASE, Cochrane Library's Central Register of Controlled Trials (CENTRAL) and SCOPUS from inception through July 2017 without date or language of publication restriction. We included studies that compared PEI with usual care (UC) in patients with acute UGIB, and reported any of the following outcomes: aspiration, pneumonia, mortality and length of stay. We excluded studies in which majority of included patients required intubation due to respiratory failure or decreased level of consciousness. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the quality of evidence for each outcome. Results: We did not identify any randomized trials on this topic. We included 10 observational studies (n = 6068). We were not able to perform any adjusted analyses. PEI was associated with a significant increase in aspiration (OR 3.85, 95% CI, 1.46, 10.25; P = 0.01; I2= 56%; low-quality evidence), pneumonia (OR 4.17, 95% CI, 1.82, 9.57; P = 0.0007; I2=52%; low-quality evidence) and hospital length of stay (mean difference 0.86 days, 95% CI 0.13, 1.59; P = 0.02; I2= 0; low-quality evidence), without clear effect on mortality (OR 1.92, 95% CI, 0.71, 5.23; P = 0.2; I2= 95%; very low-quality evidence). Conclusions: Low- to very low-quality evidence from observational studies suggests that PEI in the setting of UGIB may be associated with higher rates of respiratory complications and, less likely, with increased mortality. Although the results are alarming, the lack of higher quality evidence calls for randomized trials to inform practice.
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Affiliation(s)
- Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Roman Jaeschke
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Bandar Baw
- Division of Emergency Medicine, McMaster University, Hamilton, Canada
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
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8
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Lee S, Saxinger L, Ma M, Prado V, Fernández J, Kumar D, Gonzalez-Abraldes J, Keough A, Bastiampillai R, Carbonneau M, Fernandez J, Tandon P. Bacterial infections in acute variceal hemorrhage despite antibiotics-a multicenter study of predictors and clinical impact. United European Gastroenterol J 2017; 5:1090-1099. [PMID: 29238587 DOI: 10.1177/2050640617704564] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 03/12/2017] [Indexed: 12/31/2022] Open
Abstract
Background and aims Current guidelines recommend antibiotic prophylaxis in all patients presenting with cirrhosis and acute variceal hemorrhage (AVH). We aimed to evaluate the characteristics and clinical impact of "early" infections (developing within 14 days) of AVH in a real-world setting. Methods We analyzed retrospective data from a cohort of 371 adult patients with cirrhosis and AVH all of whom had received antibiotic prophylaxis (74% men; mean age 56 years), admitted to tertiary care hospitals in Edmonton, Alberta, Canada, and Barcelona, Spain. Sensitivity analyses were presented for culture-positive (confirmed) infections. Results The mean MELD was 16. Fifty-two percent of patients received quinolones, 45% third-generation cephalosporins and 3% other antibiotics. Fourteen percent (51/371) developed an infection within 14 days of AVH. Seventy-five percent of infections were culture positive and occurred at a mean of six days from AVH. When all infections were considered, respiratory infections were the most common (53%) followed by urinary tract infections (17%) and bacteremia (16%). Resistance patterns differed between countries. Outpatient antibiotic prophylaxis (OR 5.4) and intubation (OR 2.6) were independent predictors of bacterial infection. Bacterial infection (OR 2.6) and the MELD (OR 1.2) were independent predictors of six-week mortality. Conclusions Early bacterial infections develop in 14% of cirrhotic patients with AVH despite antibiotic prophylaxis, and have a negative impact on six-week mortality. Intubation and outpatient antibiotic prophylaxis are associated with increased risk of early bacterial infections. Patients at risk should be followed closely with prompt infection workup and local antibiogram-based expansion of antibiotic therapy in case of clinical decline.
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Affiliation(s)
- Stephen Lee
- Cirrhosis Care Clinic-Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Lynora Saxinger
- Infectious Diseases, University of Alberta, Edmonton, Alberta, Canada
| | - Mang Ma
- Cirrhosis Care Clinic-Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Verónica Prado
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain
| | - Joaquin Fernández
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain
| | - Deepali Kumar
- Infectious Diseases University of Toronto, Toronto, Ontario, Canada
| | - Juan Gonzalez-Abraldes
- Cirrhosis Care Clinic-Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Adam Keough
- Cirrhosis Care Clinic-Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Ravin Bastiampillai
- Cirrhosis Care Clinic-Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Michelle Carbonneau
- Cirrhosis Care Clinic-Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Javier Fernandez
- Infectious Diseases University of Toronto, Toronto, Ontario, Canada
| | - Puneeta Tandon
- Cirrhosis Care Clinic-Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
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Kawanishi K, Kato J, Toda N, Yamagami M, Yamada T, Kojima K, Ohki T, Seki M, Tagawa K. Risk Factors for Aspiration Pneumonia After Endoscopic Hemostasis. Dig Dis Sci 2016; 61:835-40. [PMID: 26518414 DOI: 10.1007/s10620-015-3941-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 10/22/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although all types of endoscopic procedures harbor risk of aspiration, little is understood about risk factors for aspiration pneumonia developing after endoscopic hemostasis. AIMS The present study aimed to identify risk factors for aspiration pneumonia after endoscopic hemostasis. METHODS Charts from consecutive patients with upper gastrointestinal bleeding that had been treated by endoscopic hemostasis at a single center between January 2004 and January 2015 were retrospectively reviewed. Patient information and clinical characteristics including cause of hemorrhage, established prognostic scales, laboratory data, comorbidities, medications, duration of endoscopic hemostasis, vital signs, sedative use, and the main operator during the procedure were compared between patients who developed aspiration pneumonia and those who did not. RESULTS Aspiration pneumonia developed in 24 (4.8%) of 504 patients after endoscopic hemostasis. Endotracheal intubation was required for three of them, and one died of the complication. Multivariate analysis revealed that age >75 years (odds ratio (OR) 4.4; 95% confidence interval (CI) 1.5-13.6; p = 0.0073), procedural duration >30 min (OR 5.6; 95% CI 1.9-18.2; p = 0.0023), hemodialysis (OR 3.6; 95% CI 1.2-11; p = 0.024), and a history of stroke (OR 3.8; 95% CI 1-14; p = 0.041) were independent risk factors for developing aspiration pneumonia. CONCLUSIONS Specific risk factors for aspiration pneumonia after endoscopic hemostasis were identified. Endoscopists should carefully consider aspiration pneumonia when managing older patients who are on hemodialysis, have a history of stroke, and undergo a longer procedure.
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Affiliation(s)
- Koki Kawanishi
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Jun Kato
- Second Department of Internal Medicine, Wakayama Medical University, 811 Kimiidera, Wakayama City, Wakayama, 641-0012, Japan.
| | - Nobuo Toda
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Mari Yamagami
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Tomoharu Yamada
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Kentaro Kojima
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Takamasa Ohki
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Michiharu Seki
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Kazumi Tagawa
- Department of Gastroenterology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo, 101-8643, Japan
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