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The prevention of upper gastro intestinal tract bleeding in patients in an intensive care unit

Surgery Gynecology & Obstetrics 153(2): 214-220
The prevention of upper gastro intestinal tract bleeding in patients in an intensive care unit
Upper gastrointestinal tract bleeding remains a problem in the critically ill patient. Numerous clinical and experimental studies have implicated acid as a prerequisite for the development of such lesions. A population of patients in an intensive care unit at risk for development of acute upper gastrointestinal tract bleeding was defined, and the effectiveness of prophylaxis in this population was assessed. Patients (300) were randomized into 1 of 3 treatment groups. Those in group 1 received cimetidine, 300 mg i.v. every 6 h. Those in group 2 received no additional treatment and served as a control study. Those in group 3 received antacid titration to maintain a gastric pH greater than 4.0. The population included any admission to the intensive care unit in which the patient remained longer than 48 h, excluding those with recent upper gastrointestinal tract bleeding, recent peptic ulcer disease or those patients who had undergone an operation on the esophagus or stomach. The endpoint for declaring a patient a treatment failure was persistent guaiac 4+ positive nasogastric aspirate continuous for longer than 16 h, even after nasogastric lavage; bright red bleeding per nasogastric tube or by emesis; or guaiac positive stools and a documented decrease in the hematocrit value. In the final analysis, 82% of those considered treatment failures had bright red bleeding per nasogastric tube or emesis. All groups were balanced with regard to sex, age, underlying condition, mortality and illness severity index score. The illness severity index score was assessed for each patient on the basis of 9 categories of associated illnesses. The 2 most common categories were pulmonary complications and hypotension. The overall incidence of upper gastrointestinal tract bleeding was 14% in the cimetidine-treated group, 20% in the no-treatment group and 5% in the antacid-treated group, P < 0.002. When the data were evaluated with regard to illness severity index score, cimetidine as well as antacid titration proved an effective prophylaxis in those patients who were less severely ill. In those patients who were moderately ill, with illness severity index scores of 3-6, only antacid titration proved effective. In the subgroup that was morbidly ill, with an illness severity index score of 7 or more, none of the treatments was significantly better than the control; the incidence of transfusible hemorrhage was 5% in the cimetidine-treated group, 7% in the no-treatment group and 1% in the antacid-treated group. Treatment complications were few and none posed serious threats to the patient. Cimetidine at this fixed dosage was not as effective as antacid in controlling the gastric pH. In 34% of the patients treated with cimetidine, the gastric pH was not maintained above 4.0 for longer than 8 h. The incidence of upper gastrointestinal tract bleeding in the patient in the intensive care unit can be decreased by prophylactic treatment, and the most effective form of prophylaxis is the titration of intragastrin contents with antacids.

Accession: 006740655

PMID: 7017982

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