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Prevalence and outcome of gastrointestinal bleeding and use of acid suppressants in acutely ill adult intensive care patients

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Abstract

Purpose

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.

Methods

We included adults without GI bleeding who were acutely admitted to the intensive care unit (ICU) during a 7-day period. The primary outcome was clinically important GI bleeding in ICU, and the analyses included estimations of baseline risk factors and potential associations with 90-day mortality.

Results

A total of 1,034 patients in 97 ICUs in 11 countries were included. Clinically important GI bleeding occurred in 2.6 % (95 % confidence interval 1.6–3.6 %) of patients. The following variables at ICU admission were independently associated with clinically important GI bleeding: three or more co-existing diseases (odds ratio 8.9, 2.7–28.8), co-existing liver disease (7.6, 3.3–17.6), use of renal replacement therapy (6.9, 2.7–17.5), co-existing coagulopathy (5.2, 2.3–11.8), acute coagulopathy (4.2, 1.7–10.2), use of acid suppressants (3.6, 1.3–10.2) and higher organ failure score (1.4, 1.2–1.5). In ICU, 73 % (71–76 %) of patients received acid suppressants; most received proton pump inhibitors. In patients with clinically important GI bleeding, crude and adjusted odds for mortality were 3.7 (1.7–8.0) and 1.7 (0.7–4.3), respectively.

Conclusions

In ICU patients clinically important GI bleeding is rare, and acid suppressants are frequently used. Co-existing diseases, liver failure, coagulopathy and organ failures are the main risk factors for GI bleeding. Clinically important GI bleeding was not associated with increased adjusted 90-day mortality, which largely can be explained by severity of comorbidity, other organ failures and age.

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Financial support

We received support from Aase and Ejnar Danielsens Foundation, Ehrenreichs Foundation, Scandinavian Society of Anaesthesia and Intensive Care Medicine (SSAI), the Danish Society of Anaesthesiology and Intensive care Medicine (DASAIM) and the Danish Medical Association. The funding sources had no influence on design or execution of the study, data analyses or writing of the manuscript.

Conflicts of interest

All authors have completed the Unified Competing Interest form (available on request from the corresponding author) and declare the following interests: DC received donated study drugs in 1992 from a company that does not exist anymore while leading an RCT funded by the Canadian government. The ICU at Rigshospitalet receives support for other research projects from Fresenius Kabi and CSL Behring. MW reports personal fees from KaloBios Pharmaceuticals, personal fees from Wiley Publishing, personal fees from Fisher & Paykel, personal fees from Merck (MSD) and non-financial support from Qualitech Healthcare, outside the submitted work. On behalf of all other authors the corresponding author states that there are no conflicts of interest.

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Corresponding author

Correspondence to Morten Hylander Møller.

Additional information

The SUP-ICU co-authors are listed in the “Appendix”.

Take home message: Acid suppressants are frequently prescribed as prophylaxis against gastrointestinal bleeding, but clinically important bleeding occurs infrequently. The increase in mortality in patients experiencing gastrointestinal bleeding may be explained by confounding variables. More research in this area is needed.

Electronic supplementary material

Appendix: SUP-ICU co-authors

Appendix: SUP-ICU co-authors

  • Alan Timmins, Pharmacy Department, Victoria Hospital, Kirkcaldy, UK

  • Alastair Raynes, Intensive Care Unit, Stoke Mandeville Hospital, UK

  • Alistair A. Gibson, Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, UK

  • Alma D. Moller, Department of Anaesthesia and Intensive Care, Landspitali University Hospital Reykjavik, Iceland

  • Anders Oldner, Department of Anaesthesiology, Department of Surgical Services and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden

  • Anders Perner, Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Denmark

  • Andrew P. Walden, Department of Intensive Care, Royal Berkshire Hospital, Reading, UK

  • Andrew Parsons, Pharmacy Department, Frenchay Hospital, UK

  • Anja Richter, Department of Critical Care, Whittington Health, UK

  • Anna Tilsley, Critical Care Complex, Middlemore Hospital, Auckland

  • Anna Tippett, Department of Intensive Care, Anaesthesia & Pain Medicine, Western Hospital, Western Health, Australia

  • Anne Lindhardt, Department of Intensive Care, Bispebjerg Hospital

  • Anne Berit Guttormsen, Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway

  • Arlene Robertson, Department of Intensive Care, Western General Hospital, Edinburgh, UK

  • Birgitta Lindqvist, Department of Intensive Care, Norra Älvsborgs Länssjukhus, NÄL, Trollhättan, Sweden

  • Birgitte Majholm, Department of Anesthesiology and Intensive Care, Nordsjællands Hospital, University of Copenhagen

  • Brit Sjøbø, Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway

  • Catherine Loughlin, Pharmacy Department, Countess of Chester, UK

  • Catherine McKenzie, Pharmacy Clinical Department, Guy’s and St Thomas’ NHS Foundation Trust, UK

  • Ceri Battle, Ed Major Critical Care Unit, Morriston Hospital, Swansea, Wales, UK

  • Charudatt Vaity, Cardiothoracic Intensive Care Unit, St George’s Hospital, UK

  • Cheh Kuan Tai, General Intensive Care Unit, St George’s Hospital, London, UK

  • Christina Rydahl Lundin, Department of Neuroanaesthesiology, Copenhagen University Hospital Rigshospitalet, Denmark

  • Claudia Brocke, Pharmacy Department, University Hospital Southampton, UK

  • Colin McArthur, Department of Critical Care Medicine, Auckland City Hospital, New Zealand

  • Craig French, Department of Intensive Care, Western Hospital, Western Health, Australia

  • David Lodahl, Department of Anaesthesiology and Intensive Care, Holstebro Hospital, Denmark

  • David Sapsford, Pharmacy Department, West Suffolk Hospital NHS Foundation Trust, UK

  • Deborah Cook, Department of Medicine, McMaster University, Hamilton, Ontario, Canada

  • Dhanesh Solanki, CUH Pharmacy, Croydon University Hospital NHS Trust, UK

  • Diana Ulic, Department of Medicine, McMaster University, Hamilton, Ontario, Canada

  • Dolores Beach, Pharmacy Department, University Hospital Aintree, UK

  • Edward W. Curtis, Department of Anaesthetics and Critical Care, Nevill Hall Hospital, Abergavenny, UK

  • Elisha Matheson, Department of Intensive and Critical Care Unit, Flinders Medical Centre, South Australia, Australia

  • Emma Graham-Clarke, Department of Anaesthetics, City Hospital, UK

  • Emma Louise Smith, Pharmacy Department, City Hospital, Sandwell and West Birmingham Hospitals, UK

  • Emmanuel Pelayo, Critical Care Complex, Middlemore Hospital, New Zealand

  • Fayez Ebrahim AlShamsi, Department of Critical Care, Juravinski Hospital, Hamilton, Ontario

  • Frederik Keus, University of Groningen, Department of Critical Care, University Medical Center Groningen, the Netherlands

  • Gavin Perkins, Academic Department of Anaesthesia, Critical Care, Pain and Resuscitation, Birmingham Heartlands Hospital, UK

  • Gillian Kincaid, Pharmacy Department, North Tyneside General Hospital, UK

  • Göran Anderzon, Department of Intensive Care, NÄL Trollhättan, Sweden

  • Greg Barton, Pharmacy Department, St. Helens and Knowsley Teaching Hospitals NHS Trust, UK

  • Greg Fletcher, Department of Intensive Care and Anaesthesia, Royal Derby Hospital, UK

  • Hannah Smorzaniuk, Pharmacy Department, Oxford University Hospitals NHS Trust, UK

  • Hans Friberg, Department of Anaesthesiology and Intensive Care, Skåne University Hospital, Sweden

  • Hans Michael Betsch, Intensive Care Unit, Aarhus University Hospital, Denmark

  • Helle Bundgaard, Intensive Care Unit, Randers Hospital, Denmark

  • Henrieta Jidbratt, AN/Op/IVA, Skaraborgs Sjukhus Skövde, Sweden

  • Henrik Christensen, Department of Intensive Care, Herlev Hospital, Denmark

  • Iole Brunetti, Anaesthesia and Intensive Care, IRCCS San Martino IST, Genoa, Italy

  • Jack Parry-Jones, Aneurin Bevan Health Board, Royal Gwent Hospital, UK

  • James Molony, Department of Intensive Care, Western General Hospital, Edinburgh, UK

  • Jane Stab Nielsen, Department of Anaesthesiology, Intensive Care Unit, Kolding Hospital, Denmark

  • Jeanie McAleer Elkjaer, Department of Intensive Care, Holbaek Hospital, Denmark

  • Jennifer Thomson, Pharmacy Department, University Hospital Southampton NHS Foundation Trust, UK

  • Jennifer Weston, Pharmacy Department, Oxford University Hospitals NHS Trust, UK

  • Jens C. Nilsson, Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital Rigshospitalet, Denmark

  • Jessica West, Pharmacy Department, Brighton and Sussex University Hospitals NHS Trust, UK

  • Joanne Oxlade, Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Australia

  • Joanne Price, Pharmacy Department, University Hospital Aintree, UK

  • John Adams, General Intensive Care Unit, Hammersmith Hospital, UK

  • John Muscedere, Department of Medicine, Queens University, Kingston General Hospital, Canada

  • John Santamaria, Department of Critical Care Medicine, St Vincent’s Hospital Melbourne, Australia

  • Jon Henrik Laake, Department of Anaesthesiology, Rikshospitalet Medical Centre, Oslo University Hospital, Norway

  • Julius Cranshaw, Department of Anaesthetics and Intensive Care Medicine, Royal Bournemouth Hospital, UK

  • June Landa, Pharmacy Clinical Department, Guy’s and St Thomas’ NHS Foundation Trust, UK

  • Jørn Wetterslev, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital Rigshospitalet, Denmark

  • Kate Schwartz, Department of Intensive and Critical Care Unit, Flinders Medical Centre, South Australia, Australia

  • Katie Davies, Pharmacy Department, Mid Cheshire Hospitals NHS Foundation Trust, UK

  • Katti Nwosu, Pharmacy Department, North Middlesex University Hospital NHS Trust, UK

  • Kirsty Gladas, Intensive Care Unit, Charing Cross Hospital, London, United Kingdom

  • Kris Vlahovic, Department of Critical Care, St Joseph’s Healthcare Hamilton, Ontario, Canada

  • Kristian Rørbæk Madsen, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Denmark

  • Line Malmer Madsen, Department of Anaesthesiology, Glostrup Hospital, Denmark

  • Lisa Julien, Department of Critical Care, Capital Health-Queen Elizabeth II Health Sciences Centre, Canada

  • Lone Musaeus Poulsen, Intensive Care Unit, Køge Hospital, Denmark

  • Louise Dunsmure, Pharmacy Department, Oxford University Hospitals NHS Trust, UK

  • Lynette Newby, Department of Critical Care Medicine, Auckland City Hospital, New Zealand

  • Madhankumar Vijayakumar, Department of Intensive Care, Morriston Hospital, ABM University Health Board, Swansea, UK

  • Maj Kjærgaard Kamper, Department of Anaesthesiology, Hvidovre Hospital, Denmark

  • Manu Shankar-Hari, Department of Intensive Care, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

  • Marie Sellert-Rydberg, Department of Intensive Care, County Hospital of Falun, Sweden

  • Mark Borthwick, Pharmacy Department, Oxford University Hospitals NHS Trust, UK

  • Markku Suvela, Department of Intensive Care, North Karelia Central Hospital, Joensuu, Finland

  • Markus Weis, Department of Anaesthesiology and Intensive Care Medicine, Ryhov County Hospital, Jönköping, Sweden

  • Martin Buhl Krog, Intensive Care Unit, Aarhus University Hospital, Denmark

  • Mary Madden, Regional Intensive Care Unit, Royal Victoria Hospital, UK

  • Matias Greve Lindholm, Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Denmark

  • Matt P. Wise, Department of Adult Critical Care, University Hospital of Wales, UK

  • Matthew Elliott, Department of Intensive Care and Anaesthesia, Royal Derby Hospital, UK

  • Matti Reinikainen, Department of Intensive Care, North Karelia Central Hospital, Joensuu, Finland

  • Mette Krag, Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Denmark

  • Michael Gillies, Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, UK

  • Mike Barker, Pharmacy Department, Ashford and St. Peter’s Hospitals NHS Foundation Trust, UK

  • Minna Backlund, Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, Finland

  • Morag Naysmith, Pharmacy Department, Western General Hospital, Edinburgh, UK

  • Morten Bestle, Department of Anesthesiology and Intensive Care, Nordsjællands Hospital, University of Copenhagen

  • Morten Freundlich, Intensive Care Unit, University Hospital of Aalborg, Denmark

  • Morten Hylander Møller, Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Denmark

  • Murray J. Blackstock, Intensive Care Unit, Western General Hospital, Edinburgh, UK

  • Murray Wyke-Joseph, Pharmacy Department, North Middlesex University Hospital NHS Trust, UK

  • Natalie Edwards, Department of Intensive Care, Frimley Park Hospital, UK

  • Nicole Nowell, Pharmacy Department, Frimley Park Hospital, UK

  • Niklas Nielsen, Department of Anaesthesiology and Intensive Care, Department of Clinical Sciences, Helsingborg Hospital and Lund University, Sweden

  • Olena Breum, Department of Anaesthesiology and Intensive care, Aarhus University Hospital, Denmark

  • Oliver Ralley, North Middlesex University Hospital, United Kingdom, Critical Care Complex

  • Olivia Moswela, Pharmacy Department, Oxford University Hospitals NHS Trust, UK

  • Paolo Pelosi, Anaesthesia and Intensive Care, Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino IST and University of Genoa, Italy

  • Parjam Zolfaghari, Adult Critical Care Unit, Royal London Hospital, UK

  • Paul Young, Intensive Care Unit, Wellington Regional Hospital and Intensive Care Research Programme, Medical Research Institute of New Zealand, Wellington, New Zealand

  • Pawel Stefan Berezowicz, Intensive Therapy Unit, Department of Anaesthesiology, Vejle Hospital, Part of the Lillebaelt Hospital, Denmark

  • Peter H.J. van der Voort, Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, the Netherlands

  • Peter Young, Department of Critical Care, Queen Elizabeth Hospital Kings Lynn, UK

  • Rachael Parke, Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, New Zealand

  • Raili Laru-Sompa, Department of Anaesthesiology and Intensive Care Medicine, Central Finland Central Hospital, Finland

  • Richard I. Hall, Department of Critical Care, Queen Elizabeth II Health Sciences Centre, Canada

  • Roar Medici, Department of Intensive Care, Holbaek Hospital, Denmark

  • Robert Svensson, Department of Anaesthesiology and Intensive Care Medicine, Vriinevisjukhuset in Norrkoping, Sweden

  • Samantha Bates, Department of Intensive Care, Anaesthesia & Pain Medicine, Western Hospital, Western Health, Australia

  • Sari Karlsson, Department of Intensive Care Medicine, Tampere University Hospital, Finland

  • Seppo Hovilehto, Department of Intensive Care Medicine, South Carelia Central Hospital, Finland

  • Shailesh Bihari, Intensive and Critical Care Unit, Flinders Medical Centre, Australia

  • Simon Obel Bjørn-Præst, Department of Intensive Care, Hjoerring Hospital, Denmark

  • Siv Leivdal, Intensive Care Unit, Sønderborg Hospital, Denmark

  • Staffan Pålsson, Intensive Care Unit, Norrtälje Hospital, Sweden

  • Stepani Bendel, Department of Intensive Care Medicine, Kuopio University Hospital, Finland

  • Stig Eric Dyrskog, Neuro-intensive Care Unit, Aarhus University Hospital, Denmark

  • Susan Fleury, Critical Care Program, Kingston General Hospital and Queen’s University, Kingston, Canada

  • Susan Ramsay, Adult Critical Care Unit, Royal London Hospital, UK

  • Susanne Iversen Department of Intensive Care, Slagelse Hospital, Denmark

  • Suveer Singh, Intensive Care Unit, Chelsea & Westminster Hospital, UK

  • Suzanne Odeberg-Wernerman, Department of Anaesthesia and Intensive Care Medicine, Karolinska University Hospital Huddinge, Sweden

  • Una Gunter, Intensive Care Department, Royal Gwent Hospital, Aneurin Bevan university Health Board, Newport, Wales, UK

  • Victoria Glaister, General Critical Care Unit, University Hospitals Coventry and Warwickshire NHS Trust, UK

  • Waleed Alhazzani, Department of Medicine and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada

  • Yajur Samaroo, Department of Acute Medicine, Whittington Hospital, UK

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Krag, M., Perner, A., Wetterslev, J. et al. Prevalence and outcome of gastrointestinal bleeding and use of acid suppressants in acutely ill adult intensive care patients. Intensive Care Med 41, 833–845 (2015). https://doi.org/10.1007/s00134-015-3725-1

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