What are the risk factors for gastrointestinal bleeding (HD) in critically ill patients?

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Digestive hemorrhage ( HD) due to stress ulcers is a complication with increased incidence in critically ill patients in intensive care centers (ICUs). Knowing that HD events in this patient profile increase morbidity and mortality, pharmacological prophylaxis has been implemented pAguarde enquanto o login é efetuadoara ulcer of stress, usually performed with proton pump inhibitors (IBPs). Thismeasure, although it has been shown to be effective in reducing gastrointestinal tract bleeding, can be related to potential risks such as increased infections by Clostridium difficile, pneumoniaAguarde enquanto o login é efetuado and myocardial ischemia, and its systematic adoption in critically ill patients is questioned . Based on this assumption, an attempt has been made to stratify the profile of critically ill patients at higher risk ofHD and who, consequently, would benefit more from the prophylactic use of PPI. To elucidate this issue, a systematic literature review was recently carried out followed by a meta-analysis of studies cohort and trials randomized clinical trials, aiming to define HD predictors in p adult patients of CTI. Listen also: Check- up Weekly: venous sinus thrombosis and Covid-19, gastrointestinal bleeding in cirrhosis and more! Quais são os fatores de risco para hemorragia digestiva (HD) em pacientes críticos? 

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Methodology Nthe total 8 studies were selected, corresponding to 116,497 patients with inclusion criteria several (1 study evaluated neurological patients, 2 studies patients on mechanical ventilation, with the majority using PPIs). The primary outcome assessed was the presence of clinically relevant digestive bleeding , defined as externalized HD with repercussion hemodynamics, reduced hemoglobin and need for blood transfusion. The secondary outcome evaluated was any evident digestive bleeding (EDS) during the ICU stay.Aguarde enquanto o login é efetuado

The incidence of SCR ranged between 0.6 and 2, 8%, having been analyzed 12 potential predictors for thisAguarde enquanto o login é efetuadoevent. Acute kidney injury (relative risk [RR] 2.38; confidence interval [IC] 95% 1.07-5.28; certainty moderate) and male gender (RR 1.24; 95%CI 1.03-1.5; low certainty) were statistically associated with high risk for SCR. After excluding studies with high probability of bias,Aguarde enquanto o login é efetuado coagulopathy (RR 4.76; 95%CI 2.62-8 .63; moderate certainty), shock (RR 2.60; 95%CI 1.25-5.42; blow certainty) and chronic liver disease (RR 7.64; 95%CI 3.32-17.58, moderate certainty) were also considered risk factors for SCR. The influence of mechanical ventilation remained uncertain(RR 1.93; 95%CI 0.57-6.5; very low certainty).

N Aguarde enquanto o login é efetuado the evaluation of the secondary outcome, EDS, occurred in a greater proportion (1.3 to 12.8%). A meta-analysis of 21 potential predictors for this event was performed of which 8 were statistically associated with high risk for EDS: coagulopathy (RR 2.13; 95%CI 1.31-3.45; moderate certainty), shock (RR 1.34; 95%CI 1.03-1.74; low certainty), sepsis (RR 1.16; 95%CI 1.02-1.32; moderate certainty), acute liver failure (RR 1.76; 95%CI 1.13-2.74; moderate certainty), chronic liver disease (RR 2.16; 95%CI 1.25-3.71; moderate certainty), acute kidney injury (RR 1.90; 95%CI 1.20-3.02; moderate certainty), male sex (RR 1.18; 95%CI 1.07-1.31; low certainty) and Aguarde enquanto o login é efetuado acute infarction myocardium (RR 1.65; 95%CI 1.41-1.93; low certainty). Similarly, the influence of mechanical ventilation remained uncertain (RR 1.11; 95%CI 0.64-1.91; very low certainty). Afterexclusion of studies with a high chance of bias, only coagulopathy (RR 4.14; 95%CI 2.69-6.90; moderate certainty), shock (RR 2.56; 95%CI 1.44-4.54; low certainty) and chronic liver disease (RR 4.51; 95%CI 2.30-8.85; moderate certainty) remained as risk factors for EDS. Aguarde enquanto o login é efetuadoKnow more: Find out how the management of the patient with upper gastrointestinal bleeding is

In summary, the present study reaffirmed risk factors such as coagulopathy, which have already been identified since the pfirst publications on the subject. On the other hand, previously flagged risk factorsAguarde enquanto o login é efetuado such as mechanical ventilation were not ratified in this study, being raised as a hypothesis for

jAguarde enquanto o login é efetuado to use this fact to the current adoption of mechanical ventilation protective, in addition to heterogeneity in the characteristics of mechanical ventilation in the evaluated studies, such as different times of use. In addition to factors such as acute kidney injury, shock and chronic liver disease were identified as consistent HD predictors.Aguarde enquanto o login é efetuado

What to take home

Taking into account that the The systematic prescription of PPI as stress ulcer prophylaxis is a reality in the routine of several ICUs, the analysis based on current evidence on the[IC] is valid. risk-benefit of such a measure. In this context, the identification and stratification of patients with higher risk of HD, directing to this group the use of prophylactic PPI, has been considered as a means pAguarde enquanto o login é efetuado to institute the rational and targeted use of this therapy.Aguarde enquanto o login é efetuado Aguarde enquanto o login é efetuado Author:

Resident in General Surgery at the Hospital de Clinicas da Federal University of Southern Frontier ⦁ Multiprofessional Specialization in Primary Health Care at the Federal University of Santa Catarina ⦁ Physician at the Federal University of Ceará ⦁ President of the Brazilian Department of Academic Leagues of Cardiovascular Surgery ⦁ Junior editor of the Brazilian Journal of Blog Cardiovascular Surgery ⦁ Served as Vice President member of the Brazilian Department of Academic Leagues of Cardiovascular Surgery and president of the Cardiovascular Surgery League of the Federal University of Ceará ⦁ Trainee in Cardiac Surgery at Cleveland Clinic (USA), Mount Sinai Hospital (USA), The Heart Hospital at Baylor Plano ( USA), Hôpital Européen Georges Pompidou (France), Herzzentrum Leipzig (Germany), Papworth Hospital (England), Harefield Hospital (England), St. Thomas Hospital (England), Manchester Royal Infirmary (England), Holy House of Mercy in Porto Alegre (Brazil) and Hospital São Raimundo (Brazil) ⦁ Research internship at William Harvey Heart Center (England) ⦁ Scholarship for Sandwich Graduation by the Science without Borders Program at University of Roehampton, London ⦁ Scholarship for scientific initiation CNPq, UFC and FUNCAP of the Laboratory of Inflammation and Cancer Physiology (LAFICA).

References:

      Granholm A, Zeng L, Dionne J, Perner A, Marker S, Krag M, MacLaren R, Ye Z, Moller M, Alhazzani W. Predictors of gastrointestinal bleeding in adult ICU patients: a systematic review and meta -analysis. Intensive Care Medicine. 2019;45(10):1347-1359. It hurts:

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