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Observational Study
. 2017 Jul 14;21(1):188.
doi: 10.1186/s13054-017-1780-4.

Severity of acute gastrointestinal injury grade is a predictor of all-cause mortality in critically ill patients: a multicenter, prospective, observational study

Bangchuan Hu  1 , Renhua Sun  2 , Aiping Wu  1 , Yin Ni  1 , Jingquan Liu  1 , Feng Guo  3 , Lijun Ying  4 , Guoping Ge  5 , Aijun Ding  6 , Yunchao Shi  7 , Changwen Liu  8 , Lei Xu  9 , Ronglin Jiang  10 , Jun Lu  11 , Ronghai Lin  12 , Yannan Zhu  13 , Weidong Wu  14 , Bo Xie  15
Affiliations
Observational Study

Severity of acute gastrointestinal injury grade is a predictor of all-cause mortality in critically ill patients: a multicenter, prospective, observational study

Bangchuan Hu et al. Crit Care. .

Abstract

Background: In 2012, the European Society of Intensive Care Medicine proposed a definition for acute gastrointestinal injury (AGI) based on current medical evidence and expert opinion. The aim of the present study was to evaluate the feasibility of using the current AGI grading system and to investigate the association between AGI severity grades with clinical outcome in critically ill patients.

Methods: Adult patients at 14 general intensive care units (ICUs) with an expected ICU stay ≥24 h were prospectively studied. The AGI grade was assessed daily on the basis of gastrointestinal (GI) symptoms, intra-abdominal pressures, and feeding intolerance (FI) in the first week of admission to the ICU.

Results: Among the 550 patients enrolled, 456 patients (82.9%) received mechanical ventilation, and 470 patients were identified for AGI. The distribution of the global AGI grade was 24.5% with grade I, 49.4% with grade II, 20.6% with grade III, and 5.5% with grade IV. AGI grading was positively correlated with 28- and 60-day mortality (P < 0.0001). Univariate Cox regression analysis showed that age, sepsis, diabetes mellitus, coronary artery disease, the use of vasoactive drugs, serum creatinine and lactate levels, mechanical ventilation, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and the global AGI grade were significantly (P ≤ 0.02) associated with 60-day mortality. In a multivariate analysis including these variables, diabetes mellitus (HR 1.43, 95% CI 1.03-1.87; P = 0.05), the use of vasoactive drugs (HR 1.56, 95% CI 1.12-2.11; P = 0.01), serum lactate (HR 1.15, 95% CI 1.06-1.24; P = 0.03), global AGI grade (HR 1.65, 95% CI 1.28-2.12; P = 0.008), and APACHE II score (HR 1.04, 95% CI 1.02-1.06; P < 0.001) were independently associated with 60-day mortality. In a subgroup analysis of 402 patients with 7-day survival, in addition to clinical predictors and the AGI grade on the first day of ICU stay, FI within the first week of ICU stay had an independent and incremental prognostic value for 60-day mortality (χ2 = 41.9 vs. 52.2, P = 0.007).

Conclusions: The AGI grading scheme is useful for identifying the severity of GI dysfunction and could be used as a predictor of impaired outcomes. In addition, these results support the hypothesis that persistent FI within the first week of ICU stay is an independent determinant for mortality.

Trial registration: Chinese Clinical Trial Registry identifier: ChiCTR-OCS-13003824 . Registered on 29 September 2013.

Keywords: Acute gastrointestinal injury; Critically ill patients; Feeding intolerance; Mortality.

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Conflict of interest statement

Ethics approval and consent to participate

The study protocol was approved by the local ethics committee for each hospital (Zhejiang Provincial People’s Hospital, Sir Run Run Shaw Hospital Zhejiang University School of Medicine, Shaoxing People’s Hospital, Jinhua People’s Hospital, The Third Affiliated Hospital of Zhejiang Chinese Medical University, The First Hospital of Jiaxing, Hangzhou First People’s Hospital, Ningbo Medical Treatment Center Lihuili Hospital, The First Affiliated Hospital of Zhejiang Chinese Medical University, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Taizhou Hospital of Zhejiang Province, Zhuji People’s Hospital of Zhejiang Province, the Central Hospital of Lishui City, Huzhou Central Hospital). All patients or their legal representatives provided informed written consent according to the local ethics rules.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Enrollment flowchart. AGI Acute gastrointestinal injury, EN Enteral nutrition, IAP Intra-abdominal pressure, ICU Intensive care unit, SPN Supplemental parenteral nutrition
Fig. 2
Fig. 2
Incremental prognostic value of AGI grade on the first day of ICU admission and FI within the first week of ICU stay in predicting 60-day mortality. Clinical risk factors (age, source of ICU admission, sepsis, diabetes mellitus, coronary artery disease, use of vasoactive drugs, serum creatinine and lactate levels, mechanical ventilation, and APACHE II score) were included in the multivariate regression. The χ2 value of each model for predicting all-cause mortality was calculated by the likelihood ratio test. *Significant difference of χ2 between the clinical risk factors model and clinical risk factors + AGI grade on the first day of ICU admission model (P = 0.02). **Significant difference of χ2 between the final model and the clinical risk factors + AGI grade on the first day of ICU admission model (P = 0.007). AGI Acute gastrointestinal injury, FI Feeding intolerance, ICU Intensive care unit
Fig. 3
Fig. 3
Kaplan-Meier curves stratified on the basis of global AGI grade in the overall population (a) and the patients with 7-day survival (b) for 28- and 60-day mortality. P values were for differences across the AGI grades by log-rank test. AGI Acute gastrointestinal injury
Fig. 4
Fig. 4
Kaplan-Meier curves stratified on FI within the first week of ICU stay for 28- and 60-day mortality. P values were for differences between the patients with and without FI by log-rank test. This analysis included only patients who survived for at least 7 days. FI Feeding intolerance, ICU Intensive care unit
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