Impact of Anticoagulation on Mortality and Resource Utilization Among Critically Ill Patients with Major Bleeding in the ICU
CCCF ePoster library. Fernando S. 11/13/19; 283396; EP99
Dr. Shannon Fernando
Dr. Shannon Fernando
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Topic: Retrospective or Prospective Cohort Study or Case Series

Garrick Mok, MD1; Shannon M. Fernando, MD, MSc1,2; Lana A. Castellucci, MD, MSc3,4,5; Dar Dowlatshahi, MD, PhD4,5,6; Bram Rochwerg, MD, MSc7,8; Daniel I. McIsaac, MD, MPH4,5,9; Marc Carrier, MD, MSc3,4,5; Philip S. Wells, MD, MSc3,4,5; Sean M. Bagshaw, MD, MSc10; Dean A. Fergusson, PhD, MHA4,5; Peter Tanuseputro, MD, MHSc4,5,11; Kwadwo Kyeremanteng, MD, MHA1,5,11      

From the 1Department of Emergency Medicine, University of Ottawa, Ottawa, ON; 2Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON; 3Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, ON; 4School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON; 5Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON; 6Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, ON; 7Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON; 8Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON; 9Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON; 10Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB; 11Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON.

Patients with major bleeding (e.g. gastrointestinal bleeding, and intracranial hemorrhage [ICH]) are commonly encountered in the intensive care unit (ICU). A growing number of patients are on either oral or parenteral anticoagulation (AC), but the impact of AC on outcomes of patients with major bleeding is unknown. We sought to examine this association and evaluate for potential subgroup effects between patients taking Warfarin as compared to those taking Direct Oral Anticoagulants (DOACs).        
METHODS: We analyzed a prospectively collected registry (2011-2016) from two hospitals capturing consecutive ICU patients admitted with major bleeding. “Major bleeding” was defined by the International Society on Thrombosis and Haemostasis criteria. The primary outcome, in-hospital mortality, was analyzed using a multivariable logistic regression model. Secondary outcomes included discharge to long-term care among survivors, total hospital length of stay (LOS) among survivors, and total hospital costs. 
RESULTS: 1,477 patients with major bleeding were included. AC use was found among 215 total patients (14.6%). Among OAC patients (n = 181), 141 (77.9%) had used Warfarin, and 40 (22.1%) had used a DOAC. 484 patients (32.8%) died in-hospital. AC use was associated with higher in-hospital mortality (adjusted odds ratio [OR]: 1.50 [1.17-1.93]). Among survivors to discharge, AC use was associated with higher discharge to long-term care (adjusted OR: 1.73 [1.18-2.57]), prolonged median LOS (19 days vs. 16 days, P = 0.03), and higher mean costs ($69,273 vs. $58,156, P = 0.02). With regards to OAC, a higher proportion of ICH was seen among patients on Warfarin (39.0% vs. 32.5%), as compared to DOACs. No difference in mortality was seen between DOACs and Warfarin (adjusted OR: 0.84 [0.40-1.72]). Patients with major bleeding on Warfarin had longer median LOS (11 days vs. 6 days, P = 0.03) and higher total costs ($51,524 vs. $35,176, P < 0.01) than patients on DOACs. 
CONCLUSION: Among ICU patients admitted with major bleeding, pre-admission anticoagulation use was associated with increased hospital mortality, and prolonged LOS and costs among survivors. As compared to DOACs, patients with Warfarin-associated major bleeding had increased LOS and costs. These findings have important implications in the care of ICU patients with major bleeding.

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