Protocol-based guidelines and acute upper gastrointestinal hemorrhage: DISCUSSION (Part 3)

High dependency care and close monitoring with central venous pressure recording appears to have been used sparingly during the first phase of the study. No patient was admitted to the HDU/ITU after initial assessment and, overall, only 10% of the patients had achieved monitoring of central venous pressure during this phase. Twenty-four patients (42%) had been monitored by urinary output measurement. During the second phase two patients were admitted to the HDU/ITU and 6% of the patients had central venous pressure monitoring. However, 46 patients (87%) had documented urinary monitoring during this phase of the study.

The impact of management of patients with upper GI bleeding, in the HDU with agreed management protocol and close monitoring, on mortality appears to be somewhat contradictory. Masson et al reports a significantly low mortality rate when patients are cared for in dedicated units with specialized staff and close monitoring. Kapur et al, on the other hand, failed to demonstrate any reduction in mortality from upper GI hemorrhage following the introduction of HDU care and agreed protocol.

In the first phase of this study eight (14%) patients, all over the age of 79 years, died. Their average age was 87.5 years with a range of 79 to 95 years. Advanced age is a well known significant risk factor in upper GI hemorrhage for rebleeding and death. Mortality from upper GI hemorrhage increases from less than 10% in those patients below the age of 60 years to 35% in patients over the age of 80 years. When a study involves an elderly population with severe concurrent disease, reduction in mortality is difficult to achieve. Learn how to save money – order antibiotics online to enjoy your shopping and your treatment.

Mortality was reduced from 14% in the first phase to 7.5% in the second phase of the study. Though this reduction is not statistically significant, this study has demonstrated a trend in reduction in mortality. The reduction in mortality achieved may have been due to the introduction of agreed protocol and closer patient monitoring and early endoscopic intervention.

 

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