Article 1
Risk Factors for Patient-Important Upper Gastrointestinal Bleeding. Deane AM, Lauzier F, Adhikari, N, et al. Am J Respir Crit Care Med. 2025 Sep;211(9):1671-1680.
Upper GI bleeding (UGIB) remains a relatively common complication in critically ill patients with previously identified risk factors for clinically important bleeding. The knowledge gap that the current study attempts to fill is to identify risk factors associated with patient-important UGIB. Patient-important UGIB has previously been defined by ICU survivors and family members as overt UGIB requiring a blood transfusion, vasopressor support, diagnostic endoscopy, CTA, or surgery or that results in death, disability, or prolonged hospitalization. In the recent REVISE study looking at prevention of clinically important (primary outcome) and patient-important (secondary outcome) UGIB in adult patients in the ICU on mechanical ventilation, pantoprazole was shown to decrease both, with numbers needed to treat of 40 and 37, respectively. The purpose of the current study under discussion was to identify risk factors for patient-important UGIB in mechanically ventilated patients.
This study was a planned secondary analysis of the recent REVISE study, which enrolled adult mechanically ventilated ICU patients who were randomized to receive 40 mg IV pantoprazole daily versus placebo. Those on dual antiplatelet therapy (DAPT), anticoagulation, active or recent GI bleed, or contraindication to pantoprazole were excluded. Those ventilated > 72 hours or who had received more than one daily dose equivalent of acid suppression therapy prior to randomization were also excluded. The primary outcome was development of and risk factors for patient-important UGIB as previously defined.
4,821 patients were enrolled in 68 international ICUs, with 131 patients developing patient-important UGIB and 104 developing clinical important UGIB. Risk factors for the development of patient-important UGIB included critical illness (HR 1.24, 95% CI 1.12-1.37 for every 5 increment increase in APACHE II scores), receiving inotropes or vasopressors (HR 2.05, 95% CI 1.35-3.12), severe thrombocytopenia (HR, 2.21 95% CI 1.24-3.94), and receiving antiplatelet agents (primarily ASA, as those ultimately prescribed DAPT were excluded and PPI started), HR 1.69, 95% CI 1.11-2.56. Use of pantoprazole (HR 0.36, 95% CI 0.25-0.54) and enteral tube feedings during ICU stay (HR 0.81, 95% CI 0.68-0.97 for every 500 ml increase) were associated with decreased patient-important UGIB. The use of steroids was not associated with patient-important UGIB. The risk of patient-important UGIB was lower in patients receiving PPI regardless of amount of enteral nutrition given.
Overall these results highlight risk factors for patient-important UGIB that may affect clinical decision making and also call into question the common practice of stopping stress ulcer prophylaxis once goal enteral nutrition is achieved in ventilated patients.
Article 2
Early Blood Pressure Targets in Acute Spinal Cord Injury: A Randomized Clinical Trial. Sajdeya R, Yanez ND, Kampp M, et al. JAMA Network Open. 2025 Sep 2;8(9):e2525364.
Blood pressure augmentation to maintain a mean arterial pressure (MAP) goal is a common component of early spinal cord injury (SCI) management. However, this practice is based on retrospective, observational data. This study represents the first published randomized study evaluating augmented blood pressure targets in patients with SCI.
This study is a multicenter randomized clinical trial including 13 US trauma centers between 2017 and 2023. Patients with acute SCI from blunt trauma were randomized to augmented blood pressure (ABP), targeting a MAP > 85-90, versus conventional blood pressure (CBP) targeting a MAP > 65-70. Blood pressure goals were maintained for 7 days after randomization or until intensive care unit (ICU) discharge, whichever was sooner. Primary endpoints were change in motor and sensory American Spinal Association Impairment Scale score from baseline at 6 months, and complications and organ dysfunction were secondary endpoints.
A total of 92 patients were randomized. The groups were well matched in terms of comorbidities and level of spinal cord injury. Of these, 38 patients had 6-month follow up data and 15 had died at time of follow-up. At 6 months there was no significant difference in neurologic outcomes, with no statistically significant change in upper or lower extremity motor scores, mean extremity motor scores, change in sensory scores, or total sensory scores between the groups. There were however more complications in the ABP (increased MAP goal) patients, with these patients having a higher mean SOFA score at day 3, longer mean period of mechanical ventilatory support (9.4 vs. 3.8 days), and more respiratory complications (78% vs. 39%) than the conventional group.
It is notable that the study was underpowered, with goal enrollment of 126, with early closure due to enrollment difficulties and with one-third of patients lost to follow-up. Follow-up was particularly impacted by clinic closures and transportation difficulty during the Covid-19 pandemic. Additionally, the mean MAP values in the CBP (non MAP-goal) patients was still greater than 80 mm Hg, potentially limiting the observed effect of blood pressure augmentation.
Despite limitations, the lack of neurologic benefit and increased complications from blood pressure augmentation seen in this multicenter randomized study have noted clinical implications. Clinicians should beware of interventions leading to complications during MAP augmentation, such as increased fluid resuscitation, procedural complications and prolonged ICU stay. Groups may use these data to support pursuing blood pressure augmentation only in limited patient populations or for shorter durations of time, or may consider removing MAP goal targets from institutional practices.
