Simple measures to prevent a massive upper gastrointestinal bleed.
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ABSTRACT:
SUBMITTER: Bansal R
PROVIDER: S-EPMC5538083 | biostudies-other | 2017 Aug
REPOSITORIES: biostudies-other
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Project description:ObjectiveTo develop and validate risk algorithms (QBleed) for estimating the absolute risk of upper gastrointestinal and intracranial bleed for patients with and without anticoagulation aged 21-99 years in primary care.DesignOpen cohort study using routinely collected data from general practice linked to hospital episode statistics data and mortality data during the five year study period between 1 January 2008 and 1 October 2013.Setting565 general practices in England contributing to the national QResearch database to develop the algorithm and 188 different QResearch practices to validate the algorithm. All 753 general practices had data linked to hospital episode statistics and mortality data at individual patient level.EndpointGastrointestinal bleed and intracranial bleed recorded on either the linked mortality data or the linked hospital records.ParticipantsWe studied 4.4 million patients in the derivation cohort with 16.4 million person years of follow-up. During follow-up, 21,641 patients had an incident upper gastrointestinal bleed and 9040 had an intracranial bleed. For the validation cohort, we identified 1.4 million patients contributing over 4.9 million person years of follow-up. During follow-up, 6600 patients had an incident gastrointestinal bleed and 2820 had an intracranial bleed. We excluded patients without a valid Townsend score for deprivation and those prescribed anticoagulants in the 180 days before study entry.Risk factorsCandidate variables recorded on the general practice computer system before entry to the cohort, including personal variables (age, sex, Townsend deprivation score, ethnicity), lifestyle variables (smoking, alcohol intake), chronic diseases, prescribed drugs, clinical values (body mass index, systolic blood pressure), and laboratory test results (haemoglobin, platelets). We also included previous bleed recorded before entry to the study.ResultsThe final QBleed algorithms incorporated 21 variables. When applied to the validation cohort, the algorithms in women explained 40% of the variation for upper gastrointestinal bleed and 58% for intracranial bleed. The corresponding D statistics were 1.67 and 2.42. The receiver operating curve statistic values were 0.77 and 0.86. The sensitivity values for the top 10th of men and women at highest risk were 38% and 51%, respectively. There were similar results for men.ConclusionThe QBleed algorithms provided valid measures of absolute risk of gastrointestinal and intracranial bleed in patients with and without anticoagulation as shown by the performance of the algorithms in a separate validation cohort. Further research is needed to evaluate the clinical outcomes and the cost effectiveness of using these algorithms in primary care.
| S-EPMC4113281 | biostudies-literature
Project description:IntroductionPatients with acute upper gastrointestinal bleeding may have challenging airways. This simulation teaches anesthesiology residents the skill of cricothyrotomy as a surgical last resort while managing acute bleeding in the airway.MethodsThe simulation involved a 55-year-old patient with history of alcohol abuse admitted to the ICU with hematemesis and acute blood loss for esophagogastroduodenoscopy in the ICU setting. The mannequin had tubing in the posterior oropharynx connected to a pressurized bag of simulated blood hidden from view. While conversing, the patient began to cough and gag, and the bag of fluid was opened, filling the posterior oropharynx with blood, which prompted immediate intubation attempts, designed to fail no matter what the learners attempted. When residents requested a surgical airway, they were provided with a cricothyrotomy kit and a task trainer to perform the procedure. Residents were evaluated using a behavior checklist, debriefed, then asked to complete a postsimulation survey.ResultsFifty-eight anesthesiology residents completed the simulation and provided feedback via a 5-point Likert scale of agreement. Most residents quickly recognized the need for emergency intubation. Eighty-eight percent of participants strongly agreed that the simulation was a valuable learning experience, with 99% stating it increased their confidence and clinical decision-making in handling similar scenarios in the future.DiscussionThis simulation provides a chance to practice valuable airway management skills that increase resident confidence in cricothyrotomy. Future work may examine if these skills and confidence levels are sustainable over time and if they are applied in future patient encounters.
| S-EPMC10789914 | biostudies-literature
Project description:Background: Massive transfusion in patients with upper gastrointestinal bleeding (UGIB) was not investigated. We developed a new scoring system to predict massive transfusion and to enhance care and early resource mobilization. Methods: Massive transfusion was defined as transfusion with ≥10 units of red blood cells within the first 24 h. Data were extracted from a 10-year, six-hospital database. Logistic regression was applied to derive a risk score for massive transfusion using data from 2006 to 2010, in 24,736 patients (developmental cohort). The score was then validated using data from 2011 to 2015 in 27,449 patients (validation cohort). Area under the receiver operating characteristic (AUROC) curve was performed to assess prediction accuracy. Results: Five characteristics were independently associated (p < .001) with massive transfusion: presence of band-form cells among white blood cells (band form >0), international normalized ratio (INR) >1.5, pulse >100 beats per minute or systolic blood pressure <100 mmHg (shock), haemoglobin <8.0 g/dL and endoscopic therapy. The new scoring system successfully discriminated well between UGIB patients requiring massive transfusion and those who did not in both cohorts (AUROC: 0.831, 95%CI: 0.827-0.836; AUROC: 0.822, 95% CI: 0.817-0.826, respectively). Conclusions: The new scoring system predicts massive transfusion requirement in patients with UGIB well. Key messages Massive transfusion is a life-saving management in massive upper gastrointestinal bleeding. How to identify patients requiring massive transfusion in upper gastrointestinal bleeding is poorly documented. Approximately 3.9% of upper gastrointestinal bleeding patients require massive transfusion. A new scoring system is developed to identify patients requiring massive transfusion with high accuracy.
| S-EPMC7877879 | biostudies-literature
Project description:Background and aimProphylactic endotracheal intubation for airway protection prior to endoscopy for the management of severe upper gastrointestinal bleeding (UGIB) is controversial. The aim of this meta-analysis is to examine the clinical outcomes and costs related to prophylactic endotracheal intubation compared to no intubation in UGIB.MethodsEMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials were used to identify studies through June 2017. Data regarding mortality, total hospital and intensive care unit length of stay (LOS), pneumonia, and cardiovascular events were collected. The DerSimonian-Laird random effects models were used to calculate the inverse variance-based weighted, pooled treatment effect across studies.ResultsSeven studies (five manuscripts and two abstracts) were identified (5662 total patients). Prophylactic intubation conferred an increased risk of death (odds ratio [OR], 2.59, 95% confidence interval [CI]: 1.01-6.64), hospital LOS (mean difference, 0.96 days, 95% CI: 0.26-1.67), and pneumonia (OR 6.58, 95% CI: 4.91-8.81]) compared to endoscopy without intubation. The LOS-related cost was greater when prophylactic intubation was performed ($9020 per patient, 95% CI: $6962-10 609) compared to when it was not performed ($7510 per patient, 95% CI: $6486-8432). There was no difference in risk of cardiovascular events after sensitivity analysis.ConclusionProphylactic intubation in severe UGIB is associated with a greater risk of pneumonia, LOS, death, and cost compared to endoscopy without intubation. Randomized trials examining this issue are warranted.
| S-EPMC7008165 | biostudies-literature
Project description:BackgroundNon-variceal upper gastrointestinal bleeding (NVUGIB) is a significant cause of mortality and morbidity in the USA. Currently, there are limited data on the inpatient outcomes of patients admitted with a diagnosis of NVUGIB stratified according to teaching hospital status. We analyzed data from the National Inpatient Sample (NIS) intending to evaluate these outcomes.MethodsWe queried the NIS 2016 and 2017 databases for NVUGIB hospitalizations by teaching hospital status. The primary outcome was inpatient mortality while secondary outcomes were rate of endoscopy for hemostasis, rate of early endoscopy (endoscopy in 1 day or less), mean time to endoscopy, rate of complications including acute kidney injury (AKI), acute respiratory failure (ARF), need for blood transfusion, development of sepsis, need for endotracheal intubation and mechanical ventilation as well as healthcare utilization.ResultsThere were over 71 million weighted discharges in the combined 2016 and 2017 NIS database. A total of 94,900 NVUGIB cases were identified with 63.4% admitted in teaching hospitals. The in-hospital mortality for patients admitted with an NVUGIB in teaching hospitals was 1.98% compared to 1.5% in non-teaching hospitals (adjusted odds ratio (aOR): 1.38, 95% confidence interval (CI): 1.08 - 1.77, P = 0.010) when adjusted for biodemographic and hospital characteristics as well as comorbidities. Patients admitted with a diagnosis of NVUGIB in teaching hospitals had a 10% adjusted increased odds of getting endoscopy for hemostasis (27.0% vs. 24.5%, aOR: 1.10, 95% CI: 1.02 - 1.19, P = 0.016) compared to patients in non-teaching hospitals. There was, however, no difference in early endoscopy between the two groups.ConclusionPatients admitted at teaching hospitals for an NVUGIB had worse outcomes during hospitalizations including mortality, median length of stay, and total hospital charges when compared to NVUGIB patients managed at non-teaching hospitals.
| S-EPMC8577599 | biostudies-literature
Project description:ObjectiveGastrointestinal bleeding (GIB) is an uncommon complication after abdominal surgery. Given the unique risks in the total pancreatectomy with islet autotransplant (TPIAT) population, we aimed to describe this population's incidence of postoperative GIB.MethodsProspectively collected data on patients who underwent a TPIAT from 2001 to 2018 at the University of Minnesota were reviewed for postoperative GIB. Each GIB patient was matched to a control patient and compared for medical, medication, and social history and for clinical outcomes.ResultsSixty-eight patients developed a GIB (12.4%) at median time after surgery of 17 months. Etiologies included the following: anastomotic ulcer (35%), Clostridium difficile (4%), gastric or duodenal ulcers (9%), esophagitis/gastritis (10%), hemorrhoids (3%), inflammatory bowel disease (4%), Mallory-Weiss tears (1%), and unknown (29%). During diagnostic workup, 87% had an endoscopic procedure and 3% underwent imaging. Seven patients required an operation (10%), 1 required an open embolization (1%), and 13 required endoscopic treatments (19%). Patients with a GIB were more likely to die (15% vs 5%, P = 0.055).ConclusionsTwelve percent of patients developed a GIB after TPIAT. One third of those had an undefined etiology despite endoscopy. The need for intervention was high (30%).
| S-EPMC8373743 | biostudies-literature
Project description: Not available
| S-EPMC5990427 | biostudies-literature
Project description:PurposeAfter trauma and surgery, upper gastrointestinal bleeding (UGIB) is the most common condition that can require massive transfusion (MT). The present study aimed to analyze and compare the prognostic performance of the Glasgow-Blatchford (GB), pre-endoscopy Rockall (PER), and modified early warning (MEW) scores for predicting MT in patients with unstable UGIB.Materials and methodsThis retrospective observational study included patients with UGIB from March 2016 to February 2018. Receiver operating characteristics analysis was performed to examine the prognostic performance of the GB, PER, and MEW scoring systems. Logistic regression analysis was used to identify independent risk factors for MT, after adjusting for relevant covariates. The primary outcome was MT.ResultsOf the 484 included patients with unstable UGIB, 19 (3.9%) received an MT. The areas under the curves (AUCs) of the GB, PER, and MEW scores for MT were 0.577 [95% confidence interval (CI), 0.531-0.621], 0.570 (95% CI, 0.525-0.615), and 0.767 (95% CI, 0.727-0.804), respectively. The AUC of the MEW score was significantly different from those of the GB and PER scores. In multivariate analysis, MEW score was independently associated with MT in patients with unstable UGIB (odds ratio, 1.495; 95% CI, 1.100-2.033; p=0.010).ConclusionIn unstable UGIB patients, MEW score had the best prognostic performance for MT among three scoring systems.
| S-EPMC6433562 | biostudies-literature
Project description:We represent a fatal case of atrio esophageal fistula that presented as upper GI bleed. The case was complicated by rapidly progressing multi organ dysfunction syndrome and eventual death. This was an iatrogenic complication of an elective procedure.
| S-EPMC5537396 | biostudies-other
Project description:While erythromycin has caused numerous cases of acute liver failure (ALF), clarithromycin, a similar macrolide antibiotic, has caused only six reported cases of ALF. A new case of clarithromycin-associated ALF is reported with hepatic histopathology and exclusion of other etiologies by extensive workup, and the syndrome of clarithromycin-associated ALF is better characterized by systematic review. A 60-year-old nonalcoholic man, with normal baseline liver function tests, was admitted with diffuse abdominal pain and AST = 499 U/L and ALT = 539 U/L, six days after completing a 7-day course of clarithromycin 500 mg twice daily for suspected upper respiratory infection. AST and ALT each rose to about 1,000 U/L on day-2 of admission, and rose to ≥6,000 U/L on day-3, with development of severe hepatic encephalopathy and severe coagulopathy. Planned liver biopsy was cancelled due to coagulopathies. Extensive evaluation for infectious, immunologic, and metabolic causes of liver disease was negative. Abdominal computerized tomography and abdominal ultrasound with Doppler were unremarkable. The patient developed massive, acute upper gastrointestinal bleeding associated with coagulopathies. Esophagogastroduodenoscopy was planned after massive blood product transfusions, but the patient rapidly expired from hemorrhagic shock. Autopsy revealed a golden-brown heavy liver with massive hepatic necrosis and sinusoidal congestion. Rise of AST/ALT to about 1,000 U/L each was temporally incompatible with shock liver because this rise preceded the hemorrhagic shock, but the subsequent AST/ALT rise to ≥6,000 U/L each may have had a component of shock liver. The six previously reported cases were limited by failure to exclude hepatitis E (4), lack of liver biopsy (2), and uninterpretable liver biopsy (1) and by confounding potential etiologies including disulfiram, israpidine, or recent acetaminophen use (3), clarithromycin overdose (1), active alcohol use (1), and severe heart failure (1). Review of 6 previously reported and current case of clarithromycin-associated ALF revealed that patients had AST and ALT values in the thousands. Five patients died and 2 survived.
| S-EPMC7049424 | biostudies-literature