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. We sought to define a population of patients in an intensive care unit at risk for having acute upper gastrointestinal tract bleeding develop and to assess the effectiveness of prophylaxis in this population. Three hundred patients were randomized into one of three treatment groups. Those in group 1 received cimetidine, 300 milligrams intravenously every six hours. 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 hours, 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 hours, even after nasogastric lavage; bright red bleeding per nasogastric tube or by emesis, or guaiac positive stools and a documented decrease in the hematocrit valve. 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 nine categories of associated illnesses. The two most common categories were pulmonary complications and hypotension. The over-all incidence of upper gastro-intestinal 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 having illness severity index scores of three to six, only antacid titration proved effective. In the subgroup that was morbidly ill having an illness severity index score of seven or more, none of the treatments was significantly better than the control; the incidence of transfusable hemorrhage was 5% in the cimetidine treatment group, 7% in the no treatment group and 1% per cent in the antacid treatment 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 eight hours. 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 intragastric contents with antacids.
|Number of pages
|Surgery Gynecology and Obstetrics
|Published - Jan 1 1981
ASJC Scopus subject areas
- Obstetrics and Gynecology