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Stress-Related Gastrointestinal Bleeding in Patients with Aneurysmal Subarachnoid Hemorrhage: A Multicenter Retrospective Observational Study

Neurocritical Care volume 35, pages 39–45 (2021)Cite this article

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Abstract

Background/Objective

Stress-related mucosal bleeding (SRMB) occurs in approximately 2–4% of critically ill patients. Patients with aneurysmal subarachnoid hemorrhage (aSAH) have a (diffuse) space-occupying lesion, are critically ill, often require mechanical ventilation, and frequently receive anticoagulation or antiplatelet therapy after aneurysm embolization, all of which may be risk factors for SRMB. However, no studies have evaluated SRMB in patients with aSAH. Aims of the study were to determine the incidence of SRMB in aSAH patients, evaluate the effect of acid suppression on SRMB, and identify specific risk factors for SRMB.

Methods

This was a multicenter, retrospective, observational study conducted across 17 centers. Each center reviewed up to 50 of the most recent cases of aSAH. Patients with length of stay (LOS) < 48 h or active GI bleeding on admission were excluded. Variables related to demographics, aSAH severity, gastrointestinal (GI) bleeding, provision of SRMB prophylaxis, adverse events, intensive care unit (ICU), and hospital LOS were collected for the first 21 days of admission or until hospital discharge, whichever came first. Descriptive statistics were used to analyze the data. A multivariate logistic regression modeling was utilized to examine the relationship between specific risk factors and the incidence of clinically important GI bleeding in patients with aSAH.

Results

A total of 627 patients were included. The overall incidence of clinically important GI bleeding was 4.9%. Of the patients with clinically important GI bleeding, 19 (61%) received pharmacologic prophylaxis prior to evidence of GI bleeding, while 12 (39%) were not on pharmacologic prophylaxis at the onset of GI bleeding. Patients who received an acid suppressant agent were less likely to experience GI bleeding than patients who did not receive pharmacologic prophylaxis prior to evidence of bleeding (OR 0.39, 95% CI 0.18–0.83). The multivariate regression analysis identified any instance of elevated intracranial pressure, creatinine clearance < 60 ml/min and the incidence of cerebral vasospasm as specific risk factors associated with GI bleeding. Cerebral vasospasm has not previously been described as a risk for GI bleeding (OR 2.5 95% CI 1.09–5.79).

Conclusions

Clinically important GI bleeding occurred in 4.9% of patients with aSAH, similar to the general critical care population. Risk factors associated with GI bleeding were prolonged mechanical ventilation (> 48 h), creatinine clearance < 60 ml/min, presence of coagulopathy, elevation of intracranial pressure, and cerebral vasospasm. Further prospective research is needed to confirm this observation within this patient population.

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Funding

The study was not funded. Investigators used REDCap for data entry (NIH CTSA UL1TR000117).

Author information

Authors and Affiliations

  1. University of Kentucky HealthCare, Lexington, USA

    Dina Ali & Aaron M. Cook

  2. Massachusetts General Hospital, Boston, USA

    Megan E. Barra

  3. Saint Luke’s Health System-Kansas City, Kansas City, USA

    Joseph Blunck & Justin Shewmaker

  4. Virginia Commonwealth University, Richmond, USA

    Gretchen M. Brophy

  5. Mayo Clinic, Rochester, USA

    Caitlin S. Brown & Sarah L. Clark

  6. Hospital of the University of Pennsylvania, Philadelphia, USA

    Meghan Caylor

  7. University of Michigan Hospital, Ann Arbor, USA

    David Hensler

  8. Henry Ford Hospital, Detroit, USA

    Mathew Jones

  9. Cedars-Sinai Hospital, Los Angeles, USA

    Amanda Lamer-Rosen

  10. Tampa General Hospital, Tampa, USA

    Melissa Levesque

  11. Lifespan/Rhode Island Hospital, Providence, USA

    Leana N. Mahmoud

  12. University of Alberta, Edmonton, Canada

    Sherif H. Mahmoud

  13. Ohio State Wexner Medical Center, Columbus, USA

    Casey May & Keaton Smetana

  14. Edward-Elmhurst Hospital, Chicago, USA

    Keith Nguyen

  15. Rush University Medical Center, Chicago, USA

    Nicholas Panos

  16. Novant Health, Winston-Salem, USA

    Christina Roels

  17. University Hospitals, Shaker Heights, USA

    Jessica Traeger

  18. University of Kentucky College of Pharmacy, Lexington, USA

    Aric Shadler

Authors
  1. Dina Ali
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  2. Megan E. Barra
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  3. Joseph Blunck
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  4. Gretchen M. Brophy
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  5. Caitlin S. Brown
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  6. Meghan Caylor
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  7. Sarah L. Clark
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  8. David Hensler
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  9. Mathew Jones
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  10. Amanda Lamer-Rosen
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  11. Melissa Levesque
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  12. Leana N. Mahmoud
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  13. Sherif H. Mahmoud
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  14. Casey May
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  15. Keith Nguyen
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  16. Nicholas Panos
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  17. Christina Roels
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  18. Justin Shewmaker
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  19. Keaton Smetana
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  20. Jessica Traeger
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  21. Aric Shadler
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  22. Aaron M. Cook
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Contributions

DA and AC primarily conceived the study design, but all authors had input on study design and execution. Data analysis was performed primarily by DA, AS, and AMC; all authors had input on data interpretation. DA, AS, and AMC primarily wrote the manuscript, but all authors were able to review and revise ad lib. All authors provided a final review and approval of the manuscript.

Corresponding author

Correspondence to Dina Ali.

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Conflict of interest

No pertinent conflicts of interest were reported.

Ethical Approval

The study was approved via expedited review by the University of Kentucky IRB.

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Ali, D., Barra, M.E., Blunck, J. et al. Stress-Related Gastrointestinal Bleeding in Patients with Aneurysmal Subarachnoid Hemorrhage: A Multicenter Retrospective Observational Study. Neurocrit Care 35, 39–45 (2021). https://doi.org/10.1007/s12028-020-01137-5

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  • DOI: https://doi.org/10.1007/s12028-020-01137-5

Keywords

  • Stress ulcer prophylaxis
  • Acid-suppressive therapy
  • Subarachnoid hemorrhage
  • Cerebral vasospasm
  • Proton pump inhibitors
  • Histamine-2-receptor antagonists
  • Gastrointestinal hemorrhage
  • Neurocritical care