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Risks for Developing Critical Illness With GI Hemorrhage^*

^* From the Pulmonary and Critical Care Division, Bridgeport Hospital and Yale University School of Medicine, Bridgeport, CT.

Correspondence to: Constantine A. Manthous, MD, FCCP, Bridgeport Hospital, West Tower 6, 267 Grant St, Bridgeport, CT 06610; e-mail: pcmant{at}bpthosp.org

Abstract

Study objectives: To define risk factors, identifiable on initial presentation, that predict subsequent physiologic derangements that are consistent with critical illness in patients presenting to hospital with GI hemorrhage (GIH).

Design: Observational, cohort study.

Setting: Fourteen-bed medical ICU in a 300-bed community teaching hospital.

Patients: One hundred ninety-three patients were studied during 199 separate hospital admissions for GIH.

Methods and measurements: Demographic and physiologic variables were extracted from the medical records of patients admitted with GIH. Comprehensive data, from after 2 h in the emergency department to the time of discharge or death, were used to determine whether patients met established ICU admission criteria. Physiologic and demographic data from the initial 2-h period were then compared for patients who subsequently met and for those who did not meet ICU admission criteria. Independent predictors of meeting ICU admission criteria were identified using multiple logistic regression analyses. Sensitivity and specificity associated with the combined use of these predictors were assessed.

Results: Thirty-four patients satisfied ICU admission criteria after the initial 2-h period in the emergency department. Sixty-five patients, including 29 of 34 patients who met ICU admission criteria, were actually admitted to the ICU. Among those who never fulfilled ICU admission criteria, the duration of hospital stay was longer for those admitted to the ICU than for those not admitted to ICU (6.6 ± 0.6 days vs 5.2 ± 0.3 days; p = 0.04). The admission prothrombin time (international normalized ratio > 1.2), hypotension (systolic BP < 90 mm Hg), acute neurologic changes, and initial APACHE (acute physiology and chronic health evaluation) II score ( 15) were the best independent predictors for meeting the defined criteria for admission to ICU. The presence of one or more of these in the first 2 h of presentation was associated with a sensitivity of 88% and specificity of 74% for predicting subsequent critical instability. The area under the receiver operator characteristic curve for use of these four variables was 86% for predicting whether patients met ICU admission criteria.

Conclusions: Many patients with GIH were admitted to the ICU who never met local criteria for admission, and these patients experienced a significantly longer length of hospital stay than other, similarly ill patients. Coagulopathy, hypotension, neurologic dysfunction, and a higher ( 15) APACHE II score in the first 2 h of hospitalization were the best independent predictors of the subsequent development of critical illness.

Key Words: bleeding • ICU • intensive care • risk