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Risk factors for GI haemorrhage

 

Respiratory failure and coagulopathy are associated with and increased risk of Clinically significant GI haemorrhage in the Critically ill .

Level of evidence 2+

 

Citation/s: Cook DJ, et al for the Canadian Clinical Trails Group. Risk factors for Gastrointestinal Bleeding in Critically ill patients. The New England Journal Of Medicine. 1994;330:377-81

Lead author's name and fax: Deborah J. Cook McMaster University, Hamilton, Ontario, Canada


Three-part Clinical Question: In the Critically ill, which risk factors are associated with Clinically significant Haemorrhage.


Search Terms: Critically ill, Gastrointestinal haemorrhage, bleeding, risk factor.

 

The Study: Prospective study of admissions to 4 units between June 1990 and July 1991.


The Study Patients: 2252 Intensive care patients   

                                                                                                                                             
Prognostic Factor: Coagulopathy, respiratory failure, sepsis, anticoagulation, enteral feeding

 

Exposure of Interest: Respiratory failure or Coagulopathy : Respiratory failure defined by the need for mechanical ventilation for at least 48 hours. Coagulopathy defined by a platelet count <50,000, an INR >1.5 or PTT >2.0 times control)


The Outcome: Overt bleeding (haematemesis, gross blood or coffee ground NG  aspirate, rectal bleeding, malena. Significant GI bleed (as defined as overt bleeding complicated by one of the following within 24 hours of the onset of bleeding; a spontaneous decrease of 20mmHg or more in systolic BP, an increase of more than 20 bpm in heart rate, a decrease of 10mmHg in SBP on sitting up, a decrease in Hb of more than 2g/dl and subsequent transfusion, after which the Hb did not increase by a value defined as the number of units transfused minus 2g per dl.

There was a well-defined sample at a uniform (early) stage of illness. Follow-up was long enough; follow-up was complete. There were blind, objective outcome criteria. Adjustment was not made for other prognostic factors. Can't tell if there was validation in an independent test-set of patients.

The Evidence:

Prognostic Factor Outcome Result Measure p value Independent?
Respiratory failure GI bleed while in ICU 15.6 OR p=<0.001 yes
Coagulopathy GI bleed while in ICU 4.3 OR p=<0.001 yes
Sepsis GI bleed while in ICU 2 OR p=0.07 yes
Anticoagulant therapy GI bleed while in ICU 1.1 OR p=0.88 yes
Enteral feeding GI bleed while in ICU 1 OR p=0.99 yes

The Evidence:

Significant GI bleed
Present Absent
Number Proportion Number Proportion
Respiratory failure or coagulopathy Yes 31 0.04 816 0.96
No 2 0.00 1403 1.00
Relative Risk: 25.71
Number Needed to Harm: 28 95% CI: 24.67 to 26.75
Chi Square 42.88

 

Comments:

Significant GI haemorrhage is a rare, but potentially harmful, occurrence in the critically ill patient. This study demonstrates that the two significant risk factors for GI haemorrhage are intubation and ventilation for at least 48hrs and the presence of a coagulopathy. The authors suggest that prophylaxis is merited in these patients. In patient that do not have either of these two risk factors significant GI bleeding is sufficiently rare to suggest that prophylaxis is not merited as it is not without potential risk.
 

Appraised by: Dr Chris Cairns, Spr in Anaesthetics & Intensive Care, Edinburgh Royal Infirmary
Email: Chris.Cairns@btinternet.com
Kill or Update By: March 2005

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