Upper Gastrointestinal Bleeding: Differences Between Cases Managed in an Intensive Care Unit (ICU) Versus on a Regular Floor

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Purpose: Upper gastrointestinal bleeding (UGIB) is common, with an annual incidence of 1 per 1,000 population. The mortality from UGIB ranges from 3-14%; rebleeding despite endoscopic therapy occurs in 7-16% of cases. ICU management is advisable for severe UGIB, and especially for suspected bleeding varices, but may not be always necessary. The aims of this study were to determine differences in presentation, management and outcome between cases triaged to an ICU versus a regular floor. Methods: A retrospective chart review from a tertiary care referral center. All patients >18 years admitted between August 2010 - July 2011 with either an admission or discharge diagnosis of acute UGIB were included. Patients were then classified based on their location of initial admission (ICU versus floor) and their demographic, clinical characteristics, management and outcomes were compared. Results: A total of 289 patients were identified. Their mean (range) age was 62 (18-98) years; 61% were male. Triage by emergency room physicians resulted in 96 patients being admitted to ICU and 193 patients to the floor. The presenting characteristics of these patients are in Table 1. Adverse outcomes, defined as death, transition to hospice care or a rebleed during hospitalization or within 30 days of discharge, were noted in 12.8% of the admissions for UGIB. An EGD was performed in 86% of cases and blood was transfused in 68.5% of the patients. Ninety-eight percent of ICU patients had an EGD and 99% had blood transfused, which was significantly higher than the floor group (p=<0.0001).[Image] Average length of stay and cost of hospitalization were 5 (1-62) days and $32,970 $(3,077-582,041), respectively. Table 2 shows the differences in management and outcomes.Table: [1439] Table 1. Demographics and presentation in ICU versus floor patientsTable: [1439] Table 2. Differences in management and outcomes in ICU versus floor patientsConclusion: Patients admitted to the ICU were sicker, with more frequent melena and hematemesis, lower BP, higher heart rate, lower hemoglobin, and higher BUN and INR. Risk stratification scores confirmed these observations. The 2 groups did not differ in their comorbidities. In spite of prompt endoscopy with interventions and aggressive transfusions, cases admitted to the ICU had more adverse outcomes and longer and more costly hospitalizations.Figure: [1439] Comparison of interventions performed in ICU versus floor patients: EGD and blood transfusions.