According to a quote variably attributed to Niels Bohr, Yogi Berra, Albert Einstein, Mark Twain and others ‘prediction is difficult; especially about the future’. Nevertheless, in an era of evidence-based medicine, one might surmise that the future of management of GI bleeding in the ICU will be informed by large-scale high quality RCTs. There are a number of such trials on the horizon that give us a pretty good idea of what the future holds. Based on my best-guess of what these trials will show I predict that in the future we will:
1. Use more TXA in patients with GI bleeding.
2. Use less stress ulcer prophylaxis.
The Haemorrhage ALleviation with Tranexamic acid (TXA) – InTestinal system trial (HALT-IT) is a pragmatic trial that will compare TXA to placebo in 8000 participants with clinically significant gastrointestinal bleeding. The rationale for this trial is that decreasing fibrinolysis with TXA will increase clot stability, improve haemostasis, and reduce rebleeding, leading to reduced mortality for patients presenting with GI bleeds. Additional information about the role of TXA will come from a second trial, the EXARHOSE trial, which will investigate the safety and efficacy of TXA in cirrhotic patients with acute upper GI bleeding.
There are two large-scale RCTs comparing proton pump inhibitors to placebo coming soon. The first is the SUP-ICU trial, which is being run by the Scandinavian Critical Care Trials Group. This trial will enrol adult patients with one or more risk factors for upper GI bleeding and has a primary end point of day 90 mortality. The second is the REVISE trial which includes patients who are mechanically ventilated in ICU and expected to be ventilated the day after tomorrow. REVISE has a primary end point of ‘clinically significant GI bleeding’. Together SUP-ICU and REVISE have a combined sample size of over 8000 participants and will help us to better understand the effects of PPI use on mortality risk, GI bleeding risk, VAP risk, and C. diff infection risk. The results of these trials will be complemented by the PIC-UP trial which will investigate the role of stress ulcer prophylaxis in PICU patients and the PEPTIC trial which compares PPIs and H2RBs in mechanically ventilated adults.