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      Gastrointestinal Bleeding in Patients With Acute Respiratory Distress Syndrome: A National Database Analysis

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          Abstract

          Background

          The goal of our study was to determine the impact of gastrointestinal bleeding (GIB) on in-hospital outcomes among acute respiratory distress syndrome (ARDS) patients, and subsequently determine the potential risk factors for the development of GIB.

          Methods

          ARDS patients with and without GIB were identified using the National Inpatient Sample (2002 - 2012). Linear regression analysis was used to assess impact of GIB on in-hospital mortality, length of stay and total charges. Univariate logistic regression was used to determine associated odds ratios (OR) for causes of ARDS and common comorbid conditions.

          Results

          We identified 149,190 ARDS patients. The incidence of GIB was the highest among patients > 60 years (P < 0.001). GIB was associated with longer hospitalization days (7.3 days versus 11.9 days, P < 0.001), higher mortality (11% versus 27%, P < 0.001) and greater economic burden ($82,812 versus $45,951, P < 0.001). GIB was common in cirrhosis (OR: 8.3), peptic ulcer disease (OR: 3.7), coagulopathy disorders (OR: 3.003), thrombocytopenia (OR: 2.6), anemia (OR: 2.5) and atrial fibrillation (OR: 1.5). ARDS secondary to aspiration pneumonia (OR: 2.0), pancreatitis (OR: 2.0), sepsis (OR: 1.6) and community acquired pneumonia (OR: 0.8) was more likely to have GIB.

          Conclusion

          Our study demonstrates that GIB in ARDS patients is associated with significant increased mortality, hospitalization and health care cost.

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          Most cited references27

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          Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group.

          H Fuller, Bruce Cook, D Leasa … (1994)
          The efficacy of prophylaxis against stress ulcers in preventing gastrointestinal bleeding in critically ill patients has led to its widespread use. The side effects and cost of prophylaxis, however, necessitate targeting preventive therapy to those patients most likely to benefit. We conducted a prospective multicenter cohort study in which we evaluated potential risk factors for stress ulceration in patients admitted to intensive care units and documented the occurrence of clinically important gastrointestinal bleeding (defined as overt bleeding in association with hemodynamic compromise or the need for blood transfusion). Of 2252 patients, 33 (1.5 percent; 95 percent confidence interval, 1.0 to 2.1 percent) had clinically important bleeding. Two strong independent risk factors for bleeding were identified: respiratory failure (odds ratio, 15.6) and coagulopathy (odds ratio, 4.3). Of 847 patients who had one or both of these risk factors, 31 (3.7 percent; 95 percent confidence interval, 2.5 to 5.2 percent) had clinically important bleeding. Of 1405 patients without these risk factors, 2 (0.1 percent; 95 percent confidence interval, 0.02 to 0.5 percent) had clinically important bleeding. The mortality rate was 48.5 percent in the group with bleeding and 9.1 percent in the group without bleeding (P < 0.001). Few critically ill patients have clinically important gastrointestinal bleeding, and therefore prophylaxis against stress ulcers can be safely withheld from critically ill patients unless they have coagulopathy or require mechanical ventilation.
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            Prevalence and outcome of gastrointestinal bleeding and use of acid suppressants in acutely ill adult intensive care patients.

            Mette Krag, Anders Perner, Jørn Wetterslev … (2015)
            To describe the prevalence of, risk factors for, and prognostic importance of gastrointestinal (GI) bleeding and use of acid suppressants in acutely ill adult intensive care patients.
            Article 0 comments Cited 93 times – based on 0 reviews     Review now
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              Pharmacoepidemiology of stress ulcer prophylaxis in the United States and Canada.

              Jeffrey Barletta, Ishaq Lat, Robert MacLaren … (2014)
              This study sought to identify the medication class most commonly prescribed for stress ulcer prophylaxis (SUP), assess trends in SUP utilization, and report the use of acid suppressive therapy stratified by bleeding risk. This multicenter, prospective, point prevalence study reviewed adult patients over a 24-hour period for demographics, medications used for SUP, and risk factors for clinically important bleeding. Stress ulcer prophylaxis was deemed appropriate if acid suppressive therapy was administered to patients at high risk for bleeding or no therapy in patients considered at low bleeding risk. High risk was defined as the presence of mechanical ventilation, coagulopathy, or shock. For patients receiving acid suppression before hospital admission, SUP was considered appropriate if the same drug class was continued regardless of risk factors. A planned subgroup analysis was conducted whereby patients on acid suppressive medications before admission were excluded. There were 584 patients from 58 intensive care units in 27 hospitals. The most common drug class was proton pump inhibitors (70%). Despite receiving other enteral/oral medications, 36% received intravenous acid suppressive therapy. Overall, SUP was considered appropriate in 78% of patients and 68% when patients on acid suppression before admission were excluded. When stratified by risk, acid suppressive medications were used in 92% of high-risk patients and 71% of low-risk patients. Stress ulcer prophylaxis is frequently administered to patients who are not at high risk for clinically important bleeding. Proton pump inhibitors are the overwhelming first choice among practitioners. Several opportunities exist for improvement regarding the provision of SUP. Copyright © 2014 Elsevier Inc. All rights reserved.
              Article 0 comments Cited 24 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Clin Med Res
                Journal ID (iso-abbrev): J Clin Med Res
                Journal ID (publisher-id): Elmer Press
                Title: Journal of Clinical Medicine Research
                Publisher: Elmer Press
                ISSN (Print): 1918-3003
                ISSN (Electronic): 1918-3011
                Publication date (Print): January 2019
                Publication date (Electronic): 3 December 2018
                Volume: 11
                Issue: 1
                Pages: 42-48
                Affiliations
                [a ]Department of Pulmonary & Critical Care, Staten Island University Hospital, Northwell Health, NY, USA
                [b ]Department of Internal Medicine, Staten Island University Hospital, Northwell Health, NY, USA
                [c ]Department of Gastroenterology and Hepatology, Staten Island University Hospital, Northwell Health, NY, USA
                [d ]Department of Internal Medicine, Marshfield Clinic, WI, USA
                Author notes
                [e ]Corresponding Author: Jobin Philipose, 62 Newberry Avenue, Staten Island, NY 10304, USA. Email: philipose.jobin@ 123456gmail.com
                Article
                DOI: 10.14740/jocmr3660
                PMC ID: 6306132
                PubMed ID: 30627277
                SO-VID: d10563de-d80d-4fde-861f-eebe2efb4210
                Copyright © Copyright 2019, Siddiqui et al.
                License:

                This article is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 11 October 2018
                Date accepted : 9 November 2018
                Categories
                Subject: Original Article

                ScienceOpen disciplines: Medicine
                Keywords: gastrointestinal bleeding,ards,national database analysis
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: gastrointestinal bleeding, ards, national database analysis

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