Original article
Clinical endoscopy
Prophylactic endotracheal intubation in critically ill patients undergoing endoscopy for upper GI hemorrhage

https://doi.org/10.1016/j.gie.2009.03.002Get rights and content

Background

Cardiopulmonary complications are common after endoscopy for upper GI (UGI) hemorrhage in the intensive care unit (ICU).

Objective

To evaluate the practice and outcome of elective prophylactic endotracheal intubation before endoscopy for UGI hemorrhage in the ICU.

Design

Retrospective, propensity-matched case-control study.

Setting

A 24-bed medical ICU in a tertiary center.

Patients

ICU patients who underwent endoscopy for UGI hemorrhage.

Main Outcome Measurements

Cardiopulmonary complications, ICU and hospital length of stay, and mortality. In a propensity analysis, patients who were intubated for airway protection before UGI endoscopy were matched by probability of intubation to controls who were not intubated before UGI endoscopy.

Results

Of 307 patients, 53 underwent elective prophylactic intubation before UGI endoscopy. The probability of intubation depended on the Acute Physiology and Chronic Health Evaluation III (APACHE III) score (OR 1.4; 95% CI, 1.2-1.6), age (OR 0.97; 95% CI, 0.95-0.09), the presence of hemetemesis (OR 1.9; 95% CI, 0.8-5.1), previous lung disease (OR 2.1; 95% CI, 0.8-4.9), and the number of transfusions (OR 1.1; 95% CI, 1.0-1.1 per unit). Nonintubated matched controls were identified for all but 4 patients with active massive hemetemesis, who were excluded from matched analysis. Cumulative incidence of cardiopulmonary complications (53% vs 45%, P = .414), ICU length of stay (median 2.2 vs 1.8 days, P = .138), hospital length of stay (6.9 vs 5.9 days, P = .785), and hospital mortality (14% vs 20%, P = .366) were similar.

Conclusions

Cardiopulmonary complications are frequent after endoscopy for acute UGI bleeding in ICU patients and are largely unaffected by the practice of prophylactic intubation.

Section snippets

Patients and methods

We reviewed the medical records of patients who were admitted for UGI hemorrhage to our 24-bed medical ICU at the Mayo Clinic, Rochester, Minnesota, from March 2002 to August 2006. All patients received sedation during UGI endoscopy, regardless of the extent of the endoscopic examination. The institutional review board approved the study protocol. Inclusion criteria included the presence of known cirrhosis, hemetemesis, or shock. Patients were excluded if they refused research authorization,

Results

We retrospectively identified 489 patients who had an admitting diagnosis of GI hemorrhage and who underwent a UGI endoscopy, of whom 182 were excluded (Fig. 1) because they did not meet inclusion criteria (161 patients without shock, cirrhosis, or hemetemesis), were intubated for other reasons (n = 10), denied research authorization (n = 2), or fulfilled other exclusion criteria (n = 9 patients intubated before interhospital transfer). The cumulative incidence of cardiopulmonary complications

Discussion

We observed variation in the practice of prophylactic intubation for airway protection before UGI endoscopy in patients with cirrhosis, shock, and/or hemetemesis. The probability of intubation depended on age, illness severity, the number of transfusions, and the presence or absence of preexisting lung disease. In a matched-propensity analysis, the cumulative incidence of cardiopulmonary complications did not differ significantly between patients who were or were not intubated for airway

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    In this study we used a propensity matching technique to overcome the potential for selection bias that can result because of a highly diverse patient population. A similar study evaluating the impact of PEI on 307 patients in which the final analysis was done on a matched cohort of only 49 patients in intubated and nonintubated groups showed that higher severity of illness scores, those presenting with hematemesis or requiring major blood transfusions, and a prior history of pulmonary disease were all factors associated with the likelihood of being intubated for airway protection before endoscopy for UGIB.15 Before the propensity-matched analysis, patients with brisk UGIB who were prophylactically intubated at our institution were younger but sicker as evident by higher Model of End-Stage Liver Disease, APACHE, AIMS65, and Rockall scores and a more common use of vasopressor agents before intubation.

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DISCLOSURE: All authors disclosed no financial relationships relevant to this publication. This work was supported in part by NIH grant K23 HL78743-01A1.

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