Bleeding during critical illness: a prospective cohort study using a new measurement tool.
OBJECTIVE
To estimate the incidence, severity, duration and consequences of bleeding during critical illness, and to test the performance characteristics of a new bleeding assessment tool.


METHODS
Clinical bleeding assessments were performed prospectively on 100 consecutive patients admitted to a medical-surgical intensive care unit (ICU) using a novel bleeding measurement tool called HEmorrhage MEasurement (HEME). Bleeding assessments were done daily in duplicate and independently by blinded, trained assessors. Inter-rater agreement and construct validity of the HEME tool were calculated using phi. Risk factors for major bleeding were identified using a multivariable Cox proportional hazards model.


RESULTS
Overall, 90% of patients experienced a total of 480 bleeds of which 94.8% were minor and 5.2% were major. Inter-rater reliability of the HEME tool was excellent (phi = 0.98, 95% CI: 0.96 to 0.99). A decrease in platelet count and a prolongation of partial thromboplastin time were independent risk factors for major bleeding but neither were renal failure nor prophylactic anticoagulation. Patients with major bleeding received more blood transfusions and had longer ICU stays compared to patients with minor or no bleeding.


CONCLUSIONS
Bleeding, although primarily minor, occurred in the majority of ICU patients. One of five patients experienced a major bleed which was associated with abnormal coagulation tests but not with prophylactic anticoagulants. These baseline bleeding rates can inform the design of future clinical trials in critical care that use bleeding as an outcome and HEME is a useful tool to measure bleeding in critically ill patients.
Arnold
Donald M
DM
Department of Medicine, McMaster University, Hamilton, Ontario, Canada. arnold@mcmaster.ca
Donahoe
Laura
L
Clarke
France J
FJ
Tkaczyk
Andrea J
AJ
Heels-Ansdell
Diane
D
Zytaruk
Nicole
N
Cook
Richard
R
Webert
Kathryn E
KE
McDonald
Ellen
E
Cook
Deborah J
DJ
D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D016638:Critical Illness; D003625:Data Collection / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D006470:Hemorrhage / Q000175:diagnosis* / Q000209:etiology / Q000473:pathology; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D015203:Reproducibility of Results; D012307:Risk Factors; D012720:Severity of Illness Index