Risks for developing critical illness with GI hemorrhage

Study objectives: To define risk factors, identifiable on initial presentat ion, that predict subsequent physiologic derangements that are consistent w ith 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 separat e hospital admissions for GIH. Methods and measurements: Demographic and physiologic variables were extrac ted front the medical records of patients admitted with GIH. Comprehensive data, from after 2 h in the emergency department to the time of discharge o r death, were used to determine whether patients met established ICU admiss ion 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 admi ssion criteria were identified using multiple logistic regression analyses. Sensitivity and specificity associated with the combined use of these pred ictors were assessed. Results: Thirty-four patients satisfied ICU admission criteria after the in itial 2-h period in the emergency department. Sixty-five patients, includin g 29 of 34 patients who met ICU admission criteria, were actually admitted to the ICU, Among those who never fulfilled ICU admission criteria, the dur ation of hospital stay was longer for those admitted to the ICU than for th ose not admitted to ICU (6.6 +/- 0.6 days vs 5.2 +/- 0.3 days; p = 0.04). T he admission prothrombin time (international normalized ratio > 1.2), hypot ension (systolic BP < 90 mm Hg), acute neurologic changes, and initial APAC HE (acute physiology and chronic health evaluation) II score ( greater than or equal to 15) were the best independent predictors for meeting the defin ed criteria for admission to ICU. The presence of one or more of these in t he first 2 h of presentation was associated with a sensitivity of 88% and s pecificity of 74% for predicting subsequent critical instability. The area under the receiver operator characteristic curve for use of these four vari ables 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 significantl y longer length of hospital stay than other, similarly ill patients. Coagul opathy, hypotension, neurologic dysfunction, and a higher (greater than or equal to 15) APACHE II score in the first 2 h of hospitalization were the b est independent predictors of the subsequent development of critical illnes s.