Who should receive stress ulcer prophylaxis

Patients with clinically important gastrointestinal bleeding are more likely to be those requiring mechanical ventilation (odds ratio, 16) or those who have a coagulopathy (odds ratio, 4). In patients with one or both of these risk factors, the incidence of clinically important bleeding in one natural history study was 3.7 per cent (95 per cent confidence interval, 2.5-5.2 per cent) ( Cook,etaL 1994). In patients without these risk factors, less than 0.1 per cent (95 per cent confidence interval, 0.02-0.5 per cent) had clinically important bleeding. Also, the mortality was 50 per cent; most patients died with rather than from gastrointestinal bleeding.

Therefore stress ulcer prophylaxis may be warranted most in critically ill patients who are mechanically ventilated or have a coagulopathy. Costs of clinically important gastrointestinal bleeding

To determine the prolongation of ICU stay and excess mortality attributable to clinically important bleeding, patients who bled were matched with control patients. Cost estimates for resources consumed were derived from hospital costing data. On average, each event resulted in an excess of 6.6 hematology tests, 10.8 units of transfusion products, and 23.6 days of anti-ulcer medication. Our matching procedure estimated the length of stay attributable to clinically important bleeding to be 11.4 days (95 per cent confidence interval, 6.0-28.8 days) in those patients who survived and 0.9 days (95 per cent confidence interval, 5.62-7.48 days) in patients who died, with an average of 6.5 days in all patients (95 per cent confidence interval, 12.3-25.27 days). We determined the mortality attributable to clinically important bleeding to be 12.5 per cent (95 per cent confidence interval, 38.0-63.0 per cent). The total cost of a clinically important bleeding episode was $12 215.60 (1994

Canadian dollars) (HeylaQd,,et.al 1996). Therefore clinically important bleeding results in significant morbidity and increased health care costs. To the extent that the costing system and management of critically ill patients are similar in other hospitals, these results should be generalizable to other settings.

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