Upper gastrointestinal bleeding prophylaxis: gap between guidelines and clinical practice

Background

Upper gastrointestinal bleeding (UGIB) is a common diagnosis in ICUs, especially when hemodynamic instability, mechanical ventilation and blood disorder are present. UGIB in these patients, besides prolonging the hospitalization time, significantly increases mortality. Routine prophylaxis for UGIB is therefore highly recommended.

Objective

To evaluate UGIB prophylaxis prescription in ICUs of a university hospital.

Methods

A 5-month retrospective analysis of UGIB episodes was performed, including 104 patients admitted to the ICU from 2005 September to 2006 February. Independent of what causes the hospitalization, all patients with UGIB (melena occurrence, hematemesis, gastric contents >50 ml or hemoglobin decrease >2 g/dl in 24 hours) were identified. UGIB prophylaxis prescription was also recorded and, when it occurred, the medication(s) used and the UGIB risk factors associated.

Results

The patients' median age was 62.6 years (median >71 years), and males were prevalent (60.1%). Eleven patients (10.5%) had UGIB – 10 died – and 91 (87.5%) received some prophylaxis. The major prophylaxis was ranitidine, oral management (150 mg 12/12 hours) or endovenous (50 mg 8/8 hours). Among all 104 patients, 89 (85.6%) had indication for prophylaxis, but just 78 (87.6%) of them actually received it.

In multivariable evaluation, previous bleeding, coagulation problems and hepatopathy were risk factors for UGIB (P = 0.01, P = 0.03 and P = 0.11, respectively), while prophylaxis gives protection (P = 0.034). The univariable analysis identifies heparin as a potential risk factor for bleeding (+4.9 and P = 0.026), which was not confirmed in multivariable analysis.

Conclusion

Although UGIB had high prevalence and potential severe prognosis, about 12% of all patients with a strong indication for prophylaxis do not take it in a suitable way, showing the gap between guidelines and clinical practice.