Risk Factors for Patient-Important Upper Gastrointestinal Bleeding
Adam M. Deane, François Lauzier, Neill K. J. Adhikari, François Lamontagne, Diane Heels‐Ansdell, Lehana Thabane, David Williamson, Salmaan Kanji, Jeffrey F. Barletta, Simon Finfer, Yaseen M. Arabi, Marlies Ostermann, John C. Marshall, Nicole Zytaruk, M.J. Hardie, Naomi Hammond, Gordon Guyatt, Kyle White, Karen E. A. Burns, Joanna C. Dionne, Paul J. Young, Deborah J. Cook
Abstract
Abstract Rationale Patient-important gastrointestinal bleeding is an endpoint developed by patients and family members; however, risk factors for this outcome are unknown. Objectives We sought to identify risk factors for patient-important upper gastrointestinal bleeding among invasively ventilated adults. Methods This preplanned regression analysis of an international trial database evaluated baseline and time-varying risk factors in the preceding 3 days for patient-important upper gastrointestinal bleeding, accounting for illness severity and the competing risk of death. Measurements and Main Results Patient-important upper gastrointestinal bleeding occurred in the ICU among 131 of 4,821 (2.7%) patients. Baseline APACHE II score—hazard ratio (HR), 1.24 (95% confidence interval [CI] = 1.12, 1.37) per 5-point increase—and the following were associated with greater risk of patient-important bleeding: inotropes or vasopressors (HR, 2.05 [95% CI = 1.35, 3.12]), severe thrombocytopenia (platelet count, <50 × 109/L) (HR, 2.21 [95% CI = 1.24, 3.94]) and platelet inhibitor drugs (HR, 1.69 [95% CI = 1.11, 2.56]). A lower bleeding risk was associated with pantoprazole (HR, 0.36 [95% CI = 0.25, 0.54]) and enteral nutrition (HR, 0.81 [95% CI = 0.68, 0.97]) for every increase of 500 ml/d. There was no interaction between enteral nutrition and pantoprazole (interaction P = 0.94). Allocation to pantoprazole was associated with a lower risk of patient-important upper gastrointestinal bleeding regardless of the volume of enteral nutrition (for 500 ml/d: HR, 0.36 [95% CI = 0.22, 0.58]; for no enteral nutrition: HR, 0.36 [95% CI = 0.18, 0.72]). The association of enteral nutrition and bleeding was similar with pantoprazole (HR, 0.82 [95% CI = 0.63, 1.07]) or without pantoprazole (HR, 0.81 [95% CI = 0.66, 1.00]). Conclusions Several factors are associated with the risk of patient-important upper gastrointestinal bleeding during invasive ventilation.