|
1
|
Abu El-Ella SS, El-Mekkawy MS, Mohamed Selim A. Stress ulcer prophylaxis for critically ill children: routine use needs to be re-examined. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2022; 96:402-409. [PMID: 35701033 DOI: 10.1016/j.anpede.2021.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/11/2020] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Stress ulcer prophylaxis (SUP) is commonly used in Paediatric Intensive Care Units (PICUs). However, strong evidence for this practice is lacking and there is a dire need for paediatric randomized controlled trials (RCTs). Our aim was to assess the usefulness of SUP with omeprazole in critically ill children. PATIENTS AND METHODS We conducted a randomized, controlled open-label trial, including 144 children admitted into a PICU with a paediatric Sequential Organ Failure Assessment (pSOFA) score of less than 16. We randomly allocated patients to SUP with omeprazole or no SUP. The primary outcome was development of upper gastrointestinal bleeding or nosocomial infection. RESULTS The incidence of gastrointestinal bleeding was 27.1%, but clinically significant bleeding developed in only 5.6% of patients. We did not find a significant difference in the incidence of bleeding between the prophylaxis and control groups (27.8% vs 26.4%; P = .85). We also did not find a significant difference between the groups in the incidence of ventilator-associated pneumonia (VAP) (9.6% vs 8.3%; P = .77). The incidence of central line-associated bloodstream infection (CLABSI) was higher in the prophylaxis group compared to the control group (30.6% vs 12.5%; P = .014). None of the patients developed Clostridium difficile-associated diarrhoea. We did not find significant differences in mortality, length of PICU stay or duration of mechanical ventilation. Mechanical ventilation was an independent predictor of bleeding (OR, 6.4; 95%CI, 2.73-14.9). CONCLUSION In PICU patients with mild to moderate organ dysfunction, omeprazole does not seem to be useful for prevention of gastrointestinal bleeding while at the same time increasing the risk of CLABSI. Thus, we recommend restricting SUP to mechanically ventilated children.
Collapse
Affiliation(s)
| | | | - Ali Mohamed Selim
- Departamento de Pediatría, Facultad de Medicina, Universidad de Menufia, Shibin el-Kom, Egypt
| |
Collapse
|
|
2
|
van Diepen S, Coulson T, Wang X, Opgenorth D, Zuege DJ, Harris J, Agyemang M, Niven DJ, Bellomo R, Wright SE, Young PJ, Bagshaw SM. Efficacy and safety of proton pump inhibitors versus histamine-2 receptor blockers in the cardiac surgical population: insights from the PEPTIC trial. Eur J Cardiothorac Surg 2022; 62:6537079. [PMID: 35213716 PMCID: PMC9334785 DOI: 10.1093/ejcts/ezac124] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/27/2022] [Accepted: 02/10/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The comparative effectiveness and safety of proton pump inhibitors (PPIs) versus histamine-2 receptor blockers for stress ulcer prophylaxis in the cardiac surgical intensive care unit population is uncertain. Although the Proton Pump Inhibitors versus Histamine-2 Receptor Blockers for Ulcer Prophylaxis Therapy in the Intensive Care Unit (PEPTIC) trial reported a higher risk of mortality in the PPI arm with no difference in gastrointestinal bleeding, detailed information on surgical variables and clinically relevant surgical subgroups was not available. METHODS The analysis included all Canadian cardiac surgery patients enrolled in the PEPTIC trial. Data were electronically linked using unique patient identifiers to a clinical information system. Outcomes of interest included in-hospital mortality, gastrointestinal bleeding, Clostridium difficile infections, ventilator-associated conditions and length of stay. RESULTS We studied 823 (50.6%) randomized to PPIs and 805 (49.4%) to histamine-2-receptor blockers. In the intention-to-treat analysis, there were no differences in hospital mortality [PPI: 4.3% vs histamine-2 receptor blockers: 4.8%, adjusted odds ratio (aOR) 0.97, 95% confidence interval (CI) 0.55-1.70], gastrointestinal bleeding (3.9% vs 4.8%, aOR 1.09, 95% CI 0.66-1.81), C. difficile infections (0.9% vs 0.1%, aOR 0.18, 95% CI 0.02-1.59), ventilator-associated conditions (1.6% vs 1.7%, aOR 0.92, 95% CI 0.85-1.00) or median length of stay (9.2 vs 9.8 days, adjusted risk ratio 1.06, 85% CI 0.99-1.13). No significant treatment differences were observed among subgroups of interest or per-protocol populations. CONCLUSIONS In a secondary analysis of cardiac surgery patients enrolled in the PEPTIC trial in Canada, no differences in effectiveness or safety were observed between use of PPIs and histamine-2 receptor blockers for stress ulcer prophylaxis. CLINICAL TRIAL REGISTRATION NUMBER anzctr.org.au identifier: ACTRN12616000481471.
Collapse
Affiliation(s)
- Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada,Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada,Corresponding author. 2C2 Cardiology Walter MacKenzie Center, University of Alberta Hospital, 8440-11 St., Edmonton, AB T6G 2B7, Canada. Tel: +1-780-407-6948; fax: +1-780-407-7485; e-mail: (S. van Diepen)
| | - Tim Coulson
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, VIC, Australia,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia,Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Xiaoming Wang
- Health Services Statistical and Analytic Methods, Alberta Health Services, Calgary, AB, Canada
| | - Dawn Opgenorth
- Department of Critical Care Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Danny J Zuege
- Department of Critical Care Medicine, University of Calgary, Alberta Health Services, Calgary, AB, Canada,Critical Care Strategic Clinical Network, Alberta Health Services, Calgary, AB, Canada
| | - Jo Harris
- eCritical Alberta, Alberta Health Services, Calgary, AB, Canada
| | - Malik Agyemang
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Alberta Health Services, Calgary, AB, Canada,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia,Department of Critical Care, University of Melbourne, Parkville, VIC, Australia,Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia,Data Analytics Research & Evaluation Centre, University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
| | | | - Paul J Young
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia,Department of Critical Care, University of Melbourne, Parkville, VIC, Australia,Medical Research Institute of New Zealand, Wellington, New Zealand,Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada,Critical Care Strategic Clinical Network, Alberta Health Services, Calgary, AB, Canada
| | | |
Collapse
|
|
3
|
Abu El-Ella SS, Said El-Mekkawy M, Mohamed Selim A. [Stress ulcer prophylaxis for critically ill children: Routine use needs to be re-examined]. An Pediatr (Barc) 2021; 96:S1695-4033(21)00130-2. [PMID: 33685825 DOI: 10.1016/j.anpedi.2020.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Stress ulcer prophylaxis (SUP) is commonly used in Paediatric Intensive Care Units (PICUs). However, strong evidence for this practice is lacking and there is a dire need for paediatric randomized controlled trials (RCTs). Our aim was to assess the usefulness of SUP with omeprazole in critically ill children. PATIENTS AND METHODS We conducted a randomized, controlled open-label trial, including 144 children admitted into a PICU with a paediatric Sequential Organ Failure Assessment (pSOFA) score of less than 16. We randomly allocated patients to SUP with omeprazole or no SUP. The primary outcome was development of upper gastrointestinal bleeding or nosocomial infection. RESULTS The incidence of gastrointestinal bleeding was 27.1%, but clinically significant bleeding developed in only 5.6% of patients. We did not find a significant difference in the incidence of bleeding between the prophylaxis and control groups (27.8 vs. 26.4%; p = 0.85). We also did not find a significant difference between the group in the incidence of ventilator-associated pneumonia (VAP) (9.6 vs. 8.3%; p = 0.77). The incidence of central line-associated bloodstream infection (CLABSI) was higher in the prophylaxis group compared to the control group (30.6% vs. 12.5%; p = 0.014). None of the patients developed Clostridium difficile-associated diarrhoea. We did not find significant differences in mortality, length of PICU stay or duration of mechanical ventilation. Mechanical ventilation was an independent predictor of bleeding (OR 6.4; 95% CI, 2.73-14.9). CONCLUSION In PICU patients with mild to moderate organ dysfunction, omeprazole does not seem to be useful for prevention of gastrointestinal bleeding while at the same time increasing the risk of CLABSI. Thus, we recommend restricting SUP to mechanically ventilated children.
Collapse
Affiliation(s)
| | | | - Ali Mohamed Selim
- Departamento de Pediatría, Facultad de Medicina, Universidad de Menufia, Shibin el-Kom, Egipto
| |
Collapse
|
|
4
|
Zhou X, Fang H, Xu J, Chen P, Hu X, Chen B, Wang H, Hu C, Xu Z. Stress ulcer prophylaxis with proton pump inhibitors or histamine 2 receptor antagonists in critically ill adults - a meta-analysis of randomized controlled trials with trial sequential analysis. BMC Gastroenterol 2019; 19:193. [PMID: 31752703 PMCID: PMC6873751 DOI: 10.1186/s12876-019-1105-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 10/30/2019] [Indexed: 02/08/2023] Open
Abstract
Background Proton pump inhibitors (PPI) and histamine 2 receptor antagonists (H2RA) have been widely used as stress ulcer prophylaxis (SUP) in critically ill patients, however, its efficacy and safety remain unclear. This study aimed to assess the effect of SUP on clinical outcomes in critically ill adults. Methods Literature search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane database of clinical trials for randomized controlled trials (RCTs) that investigated SUP, with PPI or H2RA, versus placebo or no prophylaxis in critically ill patients from database inception through 1 June 2019. Study selection, data extraction and quality assessment were performed in duplicate. The primary outcomes were clinically important gastrointestinal (GI) bleeding and overt GI bleeding. Conventional meta-analysis with random-effects model and trial sequential analysis (TSA) were performed. Results Twenty-nine RCTs were identified, of which four RCTs were judged as low risk of bias. Overall, SUP could reduce the incident of clinically important GI bleeding [relative risk (RR) = 0.58; 95% confidence intervals (CI): 0.42–0.81] and overt GI bleeding (RR = 0.48; 95% CI: 0.36–0.63), these results were confirmed by the sub-analysis of trials with low risk of bias, TSA indicated a firm evidence on its beneficial effects on the overt GI bleeding (TSA-adjusted CI: 0.31–0.75), but lack of sufficient evidence on the clinically important GI bleeding (TSA-adjusted CI: 0.23–1.51). Among patients who received enteral nutrition (EN), SUP was associated with a decreased risk of clinically important GI bleeding (RR = 0.61; 95% CI: 0.44–0.85; TSA-adjusted CI: 0.16–2.38) and overt GI bleeding (RR = 0.64; 95% CI: 0.42–0.96; TSA-adjusted CI: 0.12–3.35), but these benefits disappeared after adjustment with TSA. Among patients who did not receive EN, SUP had only benefits in reducing the risk of overt GI bleeding (RR = 0.37; 95% CI: 0.25–0.55; TSA-adjusted CI: 0.22–0.63), but not the clinically important GI bleeding (RR = 0.27; 95% CI: 0.04–2.09). Conclusions SUP has benefits on the overt GI bleeding in critically ill patients who did not receive EN, however, its benefits on clinically important GI bleeding still needs more evidence to confirm.
Collapse
Affiliation(s)
- Xiaoyang Zhou
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Hanyuan Fang
- Department of Emergency, Ningbo Yinzhou No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Jianfei Xu
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Peifu Chen
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Xujun Hu
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Bixin Chen
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Hua Wang
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Caibao Hu
- Department of Intensive Care Medicine, Zhejiang Hospital, Hangzhou, 310000, Zhejiang, China.
| | - Zhaojun Xu
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China.
| |
Collapse
|
|
5
|
Becq A, Urien S, Barret M, Faisy C. Epinephrine Dose Has a Preventive Effect on the Occurrence of Stress Ulcer-Induced Gastrointestinal Bleeding in Critically Ill Patients. Dig Dis Sci 2018; 63:2687-2694. [PMID: 29948567 DOI: 10.1007/s10620-018-5155-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 05/30/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Epinephrine may impair splanchnic blood flow, but the impact of epinephrine dose on the occurrence of clinically significant gastrointestinal bleeding (CSGB) caused by stress ulcer remains unclear. We investigated the effect of epinephrine dose on the occurrence of stress ulcer-related CSGB in intensive care unit (ICU) patients. METHODS In this prospective, observational, cohort study conducted in a French teaching hospital, 40 consecutive ICU patients receiving epinephrine infusion in whom a stress ulcer was diagnosed by an upper gastrointestinal endoscopy were included, from February 2010 to July 2015. The effects of epinephrine dose, and other covariates, on the occurrence of stress ulcer-related CSGB were analyzed using a multiple logistic regression model for repeated measures: At each observation, each patient serves as his own control. RESULTS A total of 1484 time-dependent epinephrine dose modifications were available for analysis. The median epinephrine dose rate was 0.8 (0-9.5) mg/h, and the median epinephrine cumulative dose was 44.8 (2.6-2343) mg. Epinephrine, expressed as the average dose per day at time t, had a significant protective effect on the occurrence of stress ulcer (odds ratio 0.22; 95% confidence interval (CI), 0.12-0.38; p < 0.0001, for a log10 increase of epinephrine dose). Enteral feeding had also a protective effect (odds ratio 0.55; 95% CI 0.41-0.72; p < 0.0001, for a log10 increase of kcal/day). Only renal replacement therapy increased the occurrence of stress ulcer in the model. CONCLUSIONS An increase in the average dose of epinephrine per day increased the time to occurrence of stress ulcer in critically ill patients.
Collapse
Affiliation(s)
- Aymeric Becq
- Department of Gastroenterology and Endoscopy, Saint Antoine Hospital, Assistance Publique - Hôpitaux de Paris, 184 rue du Faubourg Saint Antoine, 75012, Paris, France.
| | - Saik Urien
- Clinical Investigations Center-1419 INSERM, EA7323 - University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Maximilien Barret
- Department of Gastroenterology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Christophe Faisy
- Clinical Investigations Center-1419 INSERM, EA7323 - University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| |
Collapse
|
|
6
|
Use of Enteral Nutrition for Gastrointestinal Bleeding Prophylaxis in the Critically Ill: Review of Current Literature. Curr Nutr Rep 2018; 7:116-120. [PMID: 29974343 DOI: 10.1007/s13668-018-0232-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE OF REVIEW This review provides a comprehensive overview of the etiology of stress-related mucosal disease, current acid suppression therapy recommendations, and the role enteral nutrition may play in disease prevention. RECENT FINDINGS Recent literature indicates enteral nutrition may prevent complications of stress-related mucosal disease by increasing splanchnic blood flow, enhancing gastrointestinal motility, and promoting cellular immunity and integrity through local nutrient delivery. Stress-related mucosal disease is a common complication of hospitalization in the critically ill which may lead to overt gastrointestinal bleeding and enhanced mortality. High-risk patients have historically been prescribed acid suppression therapy, though enteral nutrition may also have a role in disease mitigation.
Collapse
|
|
7
|
Huang HB, Jiang W, Wang CY, Qin HY, Du B. Stress ulcer prophylaxis in intensive care unit patients receiving enteral nutrition: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:20. [PMID: 29374489 PMCID: PMC5787340 DOI: 10.1186/s13054-017-1937-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 12/27/2017] [Indexed: 12/13/2022]
Abstract
Background Pharmacologic stress ulcer prophylaxis (SUP) is recommended in critically ill patients with high risk of stress-related gastrointestinal (GI) bleeding. However, as to patients receiving enteral feeding, the preventive effect of SUP is not well-known. Therefore, we performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of pharmacologic SUP in enterally fed patients on stress-related GI bleeding and other clinical outcomes. Methods We searched PubMed, Embase, and the Cochrane database from inception through 30 Sep 2017. Eligible trials were RCTs comparing pharmacologic SUP to either placebo or no prophylaxis in enterally fed patients in the ICU. Results were expressed as risk ratio (RR) and mean difference (MD) with accompanying 95% confidence interval (CI). Heterogeneity, subgroup analysis, sensitivity analysis and publication bias were explored. Results Seven studies (n = 889 patients) were included. There was no statistically significant difference in GI bleeding (RR 0.80; 95% CI, 0.49 to 1.31, p = 0.37) between groups. This finding was confirmed by further subgroup analyses and sensitivity analysis. In addition, SUP had no effect on overall mortality (RR 1.21; 95% CI, 0.94 to 1.56, p = 0.14), Clostridium difficile infection (RR 0.89; 95% CI, 0.25 to 3.19, p = 0.86), length of stay in the ICU (MD 0.04 days; 95% CI, −0.79 to 0.87, p = 0.92), duration of mechanical ventilation (MD −0.38 days; 95% CI, −1.48 to 0.72, p = 0.50), but was associated with an increased risk of hospital-acquired pneumonia (RR 1.53; 95% CI, 1.04 to 2.27; p = 0.03). Conclusions Our results suggested that in patients receiving enteral feeding, pharmacologic SUP is not beneficial and combined interventions may even increase the risk of nosocomial pneumonia. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1937-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Hui-Bin Huang
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China.,Department of Critical Care Medicine, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350000, People's Republic of China
| | - Wei Jiang
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Chun-Yao Wang
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Han-Yu Qin
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China.
| |
Collapse
|
|
8
|
El-Kersh K, Jalil B, McClave SA, Cavallazzi R, Guardiola J, Guilkey K, Persaud AK, Furmanek SP, Guinn BE, Wiemken TL, Alhariri BC, Kellie SP, Saad M. Enteral nutrition as stress ulcer prophylaxis in critically ill patients: A randomized controlled exploratory study. J Crit Care 2017; 43:108-113. [PMID: 28865339 DOI: 10.1016/j.jcrc.2017.08.036] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 08/07/2017] [Accepted: 08/22/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE We investigated whether early enteral nutrition alone may be sufficient prophylaxis against stress-related gastrointestinal (GI) bleeding in mechanically ventilated patients. MATERIALS AND METHODS Prospective, double blind, randomized, placebo-controlled, exploratory study that included mechanically ventilated patients in medical ICUs of two academic hospitals. Intravenous pantoprazole and early enteral nutrition were compared to placebo and early enteral nutrition as stress-ulcer prophylaxis. The incidences of clinically significant and overt GI bleeding were compared in the two groups. RESULTS 124 patients were enrolled in the study. After exclusion of 22 patients, 102 patients were included in analysis: 55 patients in the treatment group and 47 patients in the placebo group. Two patients (one from each group) showed signs of overt GI bleeding (overall incidence 1.96%), and both patients experienced a drop of >3 points in hematocrit in a 24-hour period indicating a clinically significant GI bleed. There was no statistical significant difference in the incidence of overt or significant GI bleeding between groups (p=0.99). CONCLUSION We found no benefit when pantoprazole is added to early enteral nutrition in mechanically ventilated critically ill patients. The routine prescription of acid-suppressive therapy in critically ill patients who tolerate early enteral nutrition warrants further evaluation.
Collapse
Affiliation(s)
- Karim El-Kersh
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States.
| | - Bilal Jalil
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
| | - Stephen A McClave
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, KY, United States
| | - Rodrigo Cavallazzi
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
| | - Juan Guardiola
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
| | - Karen Guilkey
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
| | - Annuradha K Persaud
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Infectious Disease, University of Louisville, KY, United States
| | - Stephen P Furmanek
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Infectious Disease, University of Louisville, KY, United States
| | - Brian E Guinn
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Infectious Disease, University of Louisville, KY, United States
| | - Timothy L Wiemken
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Infectious Disease, University of Louisville, KY, United States
| | - Bashar Chihada Alhariri
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
| | - Scott P Kellie
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
| | - Mohamed Saad
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
| |
Collapse
|
|
9
|
Hammond DA, Killingsworth CA, Painter JT, Pennick RE, Chatterjee K, Boye B, Meena N. Impact of targeted educational interventions on appropriateness of stress ulcer prophylaxis in critically ill adults. Pharm Pract (Granada) 2017; 15:948. [PMID: 28943978 PMCID: PMC5597806 DOI: 10.18549/pharmpract.2017.03.948] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Accepted: 07/24/2017] [Indexed: 12/19/2022] Open
Abstract
Background: Acid suppression therapy (AST) is routinely used in critically ill patients to prevent stress-related mucosal bleeding (SRMB). Objective: Our objective was to determine the impact of a structured educational intervention on AST used for prevention of SRMB on appropriateness of AST. Methods: A single-center, retrospective, cohort study of appropriate use of AST in critically ill patients admitted to the medical intensive care unit (ICU) at an academic medical center between January to June of 2014 (no intervention) and January to June of 2015 (intervention) was conducted. The percentage of patients prescribed inappropriate AST, inappropriate AST at ICU transfer and hospital discharge, doses of inappropriate AST, and adverse effects associated with AST use were compared between periods using chi-square tests. Results: Patients in the intervention group (n=118) were 5 years older than patients in the no intervention group (n=101). AST was inappropriately initiated more frequently in the no intervention group (23% vs. 11%, p=0.012). Continuation of inappropriate AST at ICU transfer and hospital discharge was similar between groups (60% vs. 53%, p=0.277 and 18% vs. 14%, p=0.368, respectively). Conclusion: Patients had appropriate AST initiated and inappropriate AST withheld more frequently when formal education was provided. This low-cost intervention strategy can be implemented easily at institutions where pharmacists interact with physicians on rounding services and should be evaluated in institutions where interactions between pharmacists and physicians occur more frequently in non-rounding situations.
Collapse
Affiliation(s)
- Drayton A Hammond
- Assistant Professor of Pharmacy Practice. Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy. Little Rock, AR (United States).
| | | | - Jacob T Painter
- Assistant Professor of Pharmacy Practice. Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy. Little Rock, AR (United States).
| | - Rose E Pennick
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy. Little Rock, AR (United States).
| | - Kshitij Chatterjee
- Department of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences College of Medicine. Little Rock, AR (United States).
| | - Bradley Boye
- Department of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences College of Medicine. Little Rock, AR (United States).
| | - Nikhil Meena
- Assistant Professor of Medicine. Department of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences College of Medicine. Little Rock, AR (United States).
| |
Collapse
|
|
10
|
Affiliation(s)
- Alison M. Stevens
- St. Louis College of Pharmacy, Clinical Pharmacy Specialist, St. Luke's Hospital
| | - Zachariah Thomas
- Ernest Mario School of Pharmacy, Rutgers, the State University of New Jersey and Clinical Pharmacist, Hackensack University Medical Center
| |
Collapse
|
|
11
|
Abstract
Stress-related mucosal damage (SRMD) is an erosive process of the gastroduodenum that occurs frequently in critically ill patients. Symptomatic lesions may range from overt bleeding (by hematemesis, melena, bloody or coffee ground aspirates, or hematochezia) to clinically significant hemorrhage (hypotension, tachycardia, or acute anemia requiring transfusion). SRMD is caused by mucosal ischemia that produces an imbalance between injurious factors and the protective mechanisms. Common patient risk factors include mechanical ventilation, coagulopathy, shock, hepatic dysfunction, renal dysfunction, thermal injury, trauma, kidney or liver transplant, head injury or spinal cord injury, recent gastrointestinal hemorrhage, and pharmacologic interventions. Stress ulcer prophylaxis may be provided by administering one of the following pharmacologic agents: an antacid, a histamine2 receptor antagonist, sucralfate, or a proton pump inhibitor. All agents possess equal efficacies but differ in their mechanisms of action, adverse event profile, drug interactions, monitoring requirements, costs, and personnel requirements for preparation and administration. Implementation of institution-specific protocols for stress ulcer prophylaxis provides cost minimization by maximizing appropriate drug usage.
Collapse
Affiliation(s)
- Robert MacLaren
- School of Pharmacy, University of Colorado Health Sciences Center, 4200 East Ninth Avenue (C238), Denver, CO 80262,
| |
Collapse
|
|
12
|
Lin CC, Hsu YL, Chung CS, Lee TH. Stress ulcer prophylaxis in patients being weaned from the ventilator in a respiratory care center: A randomized control trial. J Formos Med Assoc 2016; 115:19-24. [DOI: 10.1016/j.jfma.2014.10.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 10/20/2014] [Accepted: 10/27/2014] [Indexed: 02/01/2023] Open
|
|
13
|
Shin S. Evaluation of costs accrued through inadvertent continuation of hospital-initiated proton pump inhibitor therapy for stress ulcer prophylaxis beyond hospital discharge: a retrospective chart review. Ther Clin Risk Manag 2015; 11:649-57. [PMID: 26005351 PMCID: PMC4420549 DOI: 10.2147/tcrm.s81759] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Background Stress ulcers and related upper gastrointestinal bleeding are well-known complications in intensive care unit (ICU) patients. Proton pump inhibitor (PPI)-based stress ulcer prophylaxis (SUP) has been widely prescribed in noncritically ill patients who are at low risk for clinically significant bleeding, which is then injudiciously continued after hospital discharge. This study aimed to evaluate the incidence of inappropriate prescribing of PPI-based preventative therapy in ICU versus non-ICU patients that subsequently continued postdischarge, and to estimate the costs incurred by the unwarranted outpatient continuation of PPI therapy. Methods A retrospective review of patient data at a major teaching hospital in Korea was performed. During the 4-year study period, adult patients who were newly initiated on PPI-based SUP during hospital admission and subsequently discharged on a PPI without a medical indication for such therapy were captured for data analysis. The incidence rates of inappropriate prescribing of PPIs were compared between ICU and non-ICU patients, and the costs associated with such therapy were also examined. Results A total of 4,410 patients, more than half of the inpatient-initiated PPI users, were deemed to have been inadvertently prescribed a PPI at discharge in the absence of a medical need for acid suppression. The incidence of inappropriate outpatient continuation of the prophylaxis was higher among ICU patients compared with non-ICU patients (57.7% versus 52.2%, respectively; P=0.001). The total expenditure accrued through the continuation of nonindicated PPI therapy was approximately US$40,175. Conclusion This study confirmed that excess usage of PPIs for SUP has spread to low-risk, non-ICU patients. The overuse of unwarranted PPI therapy can incur large health care expenditure, as well as clinical complications with minimal therapeutic benefits. Educating clinicians regarding SUP guidelines and the adverse effects of long-term use of acid suppression can improve the cost effectiveness of PPI therapy.
Collapse
Affiliation(s)
- Sooyoung Shin
- Ajou University College of Pharmacy, Yeongtong-gu, Suwon-si, Gyeonggi-do, South Korea
| |
Collapse
|
|
14
|
KRAG M, PERNER A, WETTERSLEV J, WISE MP, BORTHWICK M, BENDEL S, MCARTHUR C, COOK D, NIELSEN N, PELOSI P, KEUS F, GUTTORMSEN AB, MOLLER AD, MØLLER MH. Stress ulcer prophylaxis in the intensive care unit: an international survey of 97 units in 11 countries. Acta Anaesthesiol Scand 2015; 59:576-85. [PMID: 25880349 DOI: 10.1111/aas.12508] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 02/09/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND Stress ulcer prophylaxis (SUP) may decrease the incidence of gastrointestinal bleeding in patients in the intensive care unit (ICU), but the risk of infection may be increased. In this study, we aimed to describe SUP practices in adult ICUs. We hypothesised that patient selection for SUP varies both within and between countries. METHODS Adult ICUs were invited to participate in the survey. We registered country, type of hospital, type and size of ICU, preferred SUP agent, presence of local guideline, reported indications for SUP, criteria for discontinuing SUP, and concerns about adverse effects. Fisher's exact test was used to assess differences between groups. RESULTS Ninety-seven adult ICUs in 11 countries participated (eight European). All but one ICU used SUP, and 64% (62/97) reported having a guideline for the use of SUP. Proton pump inhibitors were the most common SUP agent, used in 66% of ICUs (64/97), and H2-receptor antagonists were used 31% (30/97) of the units. Twenty-three different indications for SUP were reported, the most frequent being mechanical ventilation. All patients were prescribed SUP in 26% (25/97) of the ICUs. Adequate enteral feeding was the most frequent reason for discontinuing SUP, but 19% (18/97) continued SUP upon ICU discharge. The majority expressed concern about nosocomial pneumonia and Clostridium difficile infection with the use of SUP. CONCLUSIONS In this international survey, most participating ICUs reported using SUP, primarily proton pump inhibitors, but many did not have a guideline; indications varied considerably and concern existed about infectious complications.
Collapse
Affiliation(s)
- M. KRAG
- Department of Intensive Care 4131; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
| | - A. PERNER
- Department of Intensive Care 4131; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
| | - J. WETTERSLEV
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
| | - M. P. WISE
- Department of Adult Critical Care; University Hospital of Wales; Cardiff UK
| | - M. BORTHWICK
- Pharmacy Department; Oxford University Hospitals NHS Trust; Oxford UK
| | - S. BENDEL
- Department of Intensive Care Medicine; Kuopio University Hospital; Kuopio Finland
| | - C. MCARTHUR
- Department of Critical Care Medicine; Auckland City Hospital; Auckland New Zealand
| | - D. COOK
- Department of Medicine; McMaster University; Hamilton Ontario Canada
| | - N. NIELSEN
- Department of Anaesthesiology and Intensive Care; Helsingborg Hospital; Sweden and Department of Clinical Sciences; Lund University; Lund Sweden
| | - P. PELOSI
- Department of Surgical Sciences and Integrated Diagnostics; IRCCS San Martino IST; University of Genoa; Genoa Italy
| | - F. KEUS
- Department of Critical Care; University of Groningen; University Medical Center Groningen; Groningen The Netherlands
| | - A. B. GUTTORMSEN
- Department of Anaesthesia and Intensive Care; Haukeland University Hospital and Clinical Institute 1 UiB; Bergen Norway
| | - A. D. MOLLER
- Department of Anaesthesia and Intensive Care; Landspitali University Hospital; Reykjavik Iceland
| | - M. H. MØLLER
- Department of Intensive Care 4131; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
| | | |
Collapse
|
|
15
|
Prevalence and outcome of gastrointestinal bleeding and use of acid suppressants in acutely ill adult intensive care patients. Intensive Care Med 2015; 41:833-45. [PMID: 25860444 DOI: 10.1007/s00134-015-3725-1] [Citation(s) in RCA: 183] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 02/27/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE To describe the prevalence of, risk factors for, and prognostic importance of gastrointestinal (GI) bleeding and use of acid suppressants in acutely ill adult intensive care patients. METHODS We included adults without GI bleeding who were acutely admitted to the intensive care unit (ICU) during a 7-day period. The primary outcome was clinically important GI bleeding in ICU, and the analyses included estimations of baseline risk factors and potential associations with 90-day mortality. RESULTS A total of 1,034 patients in 97 ICUs in 11 countries were included. Clinically important GI bleeding occurred in 2.6 % (95 % confidence interval 1.6-3.6 %) of patients. The following variables at ICU admission were independently associated with clinically important GI bleeding: three or more co-existing diseases (odds ratio 8.9, 2.7-28.8), co-existing liver disease (7.6, 3.3-17.6), use of renal replacement therapy (6.9, 2.7-17.5), co-existing coagulopathy (5.2, 2.3-11.8), acute coagulopathy (4.2, 1.7-10.2), use of acid suppressants (3.6, 1.3-10.2) and higher organ failure score (1.4, 1.2-1.5). In ICU, 73 % (71-76 %) of patients received acid suppressants; most received proton pump inhibitors. In patients with clinically important GI bleeding, crude and adjusted odds for mortality were 3.7 (1.7-8.0) and 1.7 (0.7-4.3), respectively. CONCLUSIONS In ICU patients clinically important GI bleeding is rare, and acid suppressants are frequently used. Co-existing diseases, liver failure, coagulopathy and organ failures are the main risk factors for GI bleeding. Clinically important GI bleeding was not associated with increased adjusted 90-day mortality, which largely can be explained by severity of comorbidity, other organ failures and age.
Collapse
|
|
16
|
Bardou M, Quenot JP, Barkun A. Stress-related mucosal disease in the critically ill patient. Nat Rev Gastroenterol Hepatol 2015; 12:98-107. [PMID: 25560847 DOI: 10.1038/nrgastro.2014.235] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Bleeding from stress-related mucosal disease in critically ill patients remains an important clinical management issue. Although only a small proportion (1-6%) of patients admitted to an intensive care unit (ICU) will bleed, a substantial proportion exhibit clinical risk factors (mechanical ventilation for >48 h and a coagulopathy) that predict an increased risk of bleeding. Furthermore, upper gastrointestinal mucosal lesions can be found in 75-100% of patients in ICUs. Although uncommon, stress-ulcer bleeding is a severe complication with an estimated mortality of 40-50%, mostly from decompensating an underlying condition or multiorgan failure. Although the vast majority of patients in ICUs receive stress-ulcer prophylaxis, largely with PPIs, some controversy surrounds their efficacy and safety. Indeed, no single trial has shown that stress-ulcer prophylaxis reduces mortality. Some reports suggest that the use of PPIs increases the risk of nosocomial infections. However, several meta-analyses and cost-effectiveness studies suggest PPIs to be more clinically effective and cost-effective than histamine-2 receptor antagonists, without considerable increases in nosocomial pneumonia. To help clinicians use the most appropriate strategy for treatment of patients in the ICU, this Review presents the latest information on all aspects of stress-related mucosal disease.
Collapse
Affiliation(s)
- Marc Bardou
- Gastroenterology and Hepatology Department, CHU de Dijon, France, 14 Rue Gaffarel BP77908, 21079 Dijon Cedex, France
| | - Jean-Pierre Quenot
- Medical Intensive Care Unit, CHU de Dijon, France, 14 Rue Gaffarel BP77908, 21079 Dijon Cedex, France
| | - Alan Barkun
- Gastroenterology Department, McGill University Health Centre, Montreal General Hospital Site, Room D7-346, 1650 Cedar Avenue, Montréal, QC H3G 1A4, Canada
| |
Collapse
|
|
17
|
MacLaren R, Kassel LE, Kiser TH, Fish DN. Proton pump inhibitors and histamine-2 receptor antagonists in the intensive care setting: focus on therapeutic and adverse events. Expert Opin Drug Saf 2014; 14:269-80. [DOI: 10.1517/14740338.2015.986456] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
|
|
18
|
Lenz K, Buder R, Firlinger F, Lohr G, Voglmayr M. Effect of proton pump inhibitors on gastric pH in patients exposed to severe stress. Wien Klin Wochenschr 2014; 127:51-6. [DOI: 10.1007/s00508-014-0637-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 10/07/2014] [Indexed: 12/28/2022]
|
|
19
|
Tasaka CL, Burg C, VanOsdol SJ, Bekeart L, Anglemyer A, Tsourounis C, Rennke S. An interprofessional approach to reducing the overutilization of stress ulcer prophylaxis in adult medical and surgical intensive care units. Ann Pharmacother 2014; 48:462-9. [PMID: 24473490 DOI: 10.1177/1060028013517088] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Overutilization of stress ulcer prophylaxis (SUP) in the intensive care unit (ICU) is common. Acid-suppressive therapies routinely used for SUP are best reserved for patients with greatest risk of clinically important bleeding as they have been associated with nosocomial pneumonia, Clostridium difficile infection and increased hospital cost. OBJECTIVE The primary objective was to reduce inappropriate utilization of SUP in 2 adult medical and surgical ICU settings at the University of California, San Francisco Medical Center. Secondary objectives included reduction of inappropriate continuation of SUP at ICU and hospital discharge. METHODS To attain the study objective, an interprofessional team developed a bundled quality improvement initiative, including an institution SUP guideline, pharmacist-led intervention, and an education and awareness campaign. To assess the impact of these interventions, we conducted a retrospective cohort study comparing data on prescribing practices at baseline before and after the intervention. Since computerized prescriber order entry (CPOE) was implemented during this time frame, preintervention data collection consisted of 2 periods, one before and one after CPOE implementation. RESULTS The incidence of the inappropriate use of SUP was not significantly different between the pre-CPOE and post-CPOE groups (20 and 19 per 100 patient-days, respectively; P = .88), but the incidence of inappropriate use of SUP was significantly lower in the postintervention group versus the post-CPOE group (9 and 19 per 100 patient-days, respectively; P = .03). At ICU discharge, 4% of patients in the post-intervention group were discharged inappropriately on SUP compared with 8% in the post-CPOE group (P = .54). At hospital discharge, none of the patients in the postintervention group were discharged inappropriately on SUP compared with 7% in the post-CPOE group (P = .22). CONCLUSIONS Implementation of an interprofessional bundled quality improvement initiative is effective in decreasing inappropriate use of SUP in adult medical and surgical ICUs at a university-affiliated, tertiary care academic medical center.
Collapse
|
|
20
|
KRAG M, PERNER A, WETTERSLEV J, MØLLER MH. Stress ulcer prophylaxis in the intensive care unit: is it indicated? A topical systematic review. Acta Anaesthesiol Scand 2013; 57:835-47. [PMID: 23495933 DOI: 10.1111/aas.12099] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2013] [Indexed: 12/18/2022]
Abstract
UNLABELLED Stress ulcer prophylaxis (SUP) is regarded as standard of care in the intensive care unit (ICU). However, recent randomized, clinical trials (RCTs) and meta-analyses have questioned the rationale and level of evidence for this recommendation. The aim of the present systematic review was to evaluate if SUP in the critically ill patients is indicated. DATA SOURCES MEDLINE including MeSH, EMBASE, and the Cochrane Library. PARTICIPANTS patients in the ICU. INTERVENTIONS pharmacological and non-pharmacological SUP. STUDY APPRAISAL AND SYNTHESIS METHODS Risk of bias was assessed according to Grading of Recommendations Assessment, Development, and Evaluation, and risk of random errors in cumulative meta-analyses was assessed with trial sequential analysis. A total of 57 studies were included in the review. The literature on SUP in the ICU includes limited trial data and methodological weak studies. The reported incidence of gastrointestinal (GI) bleeding varies considerably. Data on the incidence and severity of GI bleeding in general ICUs in the developed world as of today are lacking. The best intervention for SUP is yet to be settled by balancing efficacy and harm. In essence, it is unresolved if intensive care patients benefit overall from SUP. The following clinically research questions are unanswered: (1) What is the incidence of GI bleeding, and which interventions are used for SUP in general ICUs today?; (2) Which criteria are used to prescribe SUP?; (3) What is the best SUP intervention?; (4) Do intensive care patients benefit from SUP with proton pump inhibitors as compared with other SUP interventions? Systematic reviews of possible interventions and well-powered observational studies and RCTs are needed.
Collapse
Affiliation(s)
- M. KRAG
- Department of Intensive Care; Copenhagen University Hospital; Rigshospitalet; Denmark
| | - A. PERNER
- Department of Intensive Care; Copenhagen University Hospital; Rigshospitalet; Denmark
| | - J. WETTERSLEV
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen University Hospital; Rigshospitalet; Denmark
| | - M. H. MØLLER
- Department of Intensive Care; Copenhagen University Hospital; Rigshospitalet; Denmark
| |
Collapse
|
|
21
|
Proton pump inhibitors versus histamine 2 receptor antagonists for stress ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis. Crit Care Med 2013; 41:693-705. [PMID: 23318494 DOI: 10.1097/ccm.0b013e3182758734] [Citation(s) in RCA: 182] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Critically ill patients may develop bleeding caused by stress ulceration. Acid suppression is commonly prescribed for patients at risk of stress ulcer bleeding. Whether proton pump inhibitors are more effective than histamine 2 receptor antagonists is unclear. OBJECTIVES To determine the efficacy and safety of proton pump inhibitors vs. histamine 2 receptor antagonists for the prevention of upper gastrointestinal bleeding in the ICU. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, ACPJC, CINHAL, online trials registries (clinicaltrials.gov, ISRCTN Register, WHO ICTRP), conference proceedings databases, and reference lists of relevant articles. SELECTION CRITERIA Randomized controlled parallel group trials comparing proton pump inhibitors to histamine 2 receptor antagonists for the prevention of upper gastrointestinal bleeding in critically ill patients, published before March 2012. DATA COLLECTION AND ANALYSIS Two reviewers independently applied eligibility criteria, assessed quality, and extracted data. The primary outcomes were clinically important upper gastrointestinal bleeding and overt upper gastrointestinal bleeding; secondary outcomes were nosocomial pneumonia, ICU mortality, ICU length of stay, and Clostridium difficile infection. Trial authors were contacted for additional or clarifying information. RESULTS Fourteen trials enrolling a total of 1,720 patients were included. Proton pump inhibitors were more effective than histamine 2 receptor antagonists at reducing clinically important upper gastrointestinal bleeding (relative risk 0.36; 95% confidence interval 0.19-0.68; p = 0.002; I = 0%) and overt upper gastrointestinal bleeding (relative risk 0.35; 95% confidence interval 0.21-0.59; p < 0.0001; I = 15%). There were no differences between proton pump inhibitors and histamine 2 receptor antagonists in the risk of nosocomial pneumonia (relative risk 1.06; 95% confidence interval 0.73-1.52; p = 0.76; I = 0%), ICU mortality (relative risk 1.01; 95% confidence interval 0.83-1.24; p = 0.91; I = 0%), or ICU length of stay (mean difference -0.54 days; 95% confidence interval -2.20 to 1.13; p = 0.53; I = 39%). No trials reported on C. difficile infection. CONCLUSIONS In critically ill patients, proton pump inhibitors seem to be more effective than histamine 2 receptor antagonists in preventing clinically important and overt upper gastrointestinal bleeding. The robustness of this conclusion is limited by the trial methodology, differences between lower and higher quality trials, sparse data, and possible publication bias. We observed no differences between drugs in the risk of pneumonia, death, or ICU length of stay.
Collapse
|
|
22
|
Chen C, Zhang F, Zhang Z, Peng M, Wang Y, Chen Y. TLR4 signaling-induced heme oxygenase upregulation in the acute lung injury: role in hemorrhagic shock and two-hit induced lung inflammation. Mol Biol Rep 2013; 40:1167-72. [PMID: 23065289 DOI: 10.1007/s11033-012-2158-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 10/06/2012] [Indexed: 12/19/2022]
Abstract
Resuscitated hemorrhagic shock is believed to promote the development of acute lung injury (ALI) by priming the immune system for an exaggerated inflammatory response to a second trivial stimulus. This work explored effects of TLR4 on hemorrhage-induced ALI and "second-hit" responses, and further explore the mechanisms involved in "second-hit" responses. Expression of HO-1, IL-10, lung W/D and MPO markedly increased at nearly all time-points examined in HSR/LPS group as compared with sham/LPS group in WT mice. In HSR/LPS mice, the induced amount of IL-10 and the expressions of HO-1 of WT mice were significantly higher compared with TLR-4d/d. This study provides in vivo evidence that pulmonary infections after LPS instillation contribute to local tissue release of pro-inflammatory mediators after HSR systemic. Activation of TLR4 might induce HO-1 expression and HO-1 modulates proinflammatory responses that are triggered via TLR4 signaling.
Collapse
Affiliation(s)
- Chang Chen
- Department of Anesthesiology, Zhongnan Hospital, Medical College of Wuhan University, Donghu Road, Wuhan, 430071, Hubei, People's Republic of China
| | | | | | | | | | | |
Collapse
|
|
23
|
Mutlu GM, Mutlu EA, Factor P. Prevention and Treatment of Gastrointestinal Complications in Patients on Mechanical Ventilation. ACTA ACUST UNITED AC 2012; 2:395-411. [PMID: 14719992 DOI: 10.1007/bf03256667] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
There exists a complex, dynamic interaction between mechanical ventilation and the splanchnic vasculature that contributes to a myriad of gastrointestinal tract complications that arise during critical illness. Positive pressure-induced splanchnic hypoperfusion appears to play a pivotal role in the pathogenesis of these complications, the most prevalent of which are stress-related mucosal damage, gastrointestinal hypomotility and diarrhea. Furthermore, characteristics of the splanchnic vasculature make the gastrointestinal tract vulnerable to adverse effects related to positive pressure ventilation. While most of these complications seen in mechanically ventilated patients are reflections of altered gastrointestinal physiology, some may be attributed to medical interventions instituted to treat critical illness. Since maintenance of normal hemodynamics cannot always be achieved, pharmacologic prophylactic therapy has become a mainstay in the prevention of gastrointestinal complications in the intensive care unit. Improved understanding of the systemic effects of mechanical ventilation and greater application of lung-protective ventilatory strategies may potentially minimize positive pressure-induced reductions in splanchnic perfusion, systemic cytokine release and, consequently, reduce the incidence of gastrointestinal complications associated with mechanical ventilation. Herein, we discuss the pathophysiology of gastrointestinal complications associated with mechanical ventilation, summarize the most prevalent complications and focus on preventive strategies and available treatment options for these complications. The most common causes of gastrointestinal hemorrhage in mechanically ventilated patients are bleeding from stress-related mucosal damage and erosive esophagitis. In general, histamine H(2) receptor antagonists and proton pump inhibitors prevent stress-related mucosal disease by raising the gastric fluid pH. Proton pump inhibitors tend to provide more consistent pH control than histamine H(2) receptor antagonists. There is no consensus on the drug of choice for stress ulcer prophylaxis with several meta-analyses providing conflicting results on the superiority of any medication. Prevention of erosive esophagitis include careful use of nasogastric tubes and institution of strategies that improve gastric emptying. Many mechanically ventilated patients have gastrointestinal hypomotility and diarrhea. Treatment options for gastrointestinal motility are limited, thus, preventive measures such as correction of electrolyte abnormalities and avoidance of medications that impair gastrointestinal motility are crucial. Treatment of diarrhea depends on the underlying cause. When associated with Clostridium difficile infection antibacterial therapy should be discontinued, if possible, and treatment with oral metronidazole should be initiated.More studies are warranted to better understand the systemic effects of mechanical ventilation on the gastrointestinal tract and to investigate the impact of lung protective ventilatory strategies on gastrointestinal complications.
Collapse
Affiliation(s)
- Gökhan M Mutlu
- Division of Pulmonary and Critical Care Medicine, Evanston Northwestern Healthcare, Evanston Illinois and Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
| | | | | |
Collapse
|
|
24
|
VOORT PHJVANDER, HULST RWMVANDER, ZANDSTRA DF, ENDE AVANDER, GERAEDTS AAM, TYTGAT GNJ. Detection ofHelicobacter pyloriin mechanically ventilated patients: the LARA-13C-urea breath test and serology. ACTA ACUST UNITED AC 2011. [DOI: 10.3109/tcic.10.3.91.95] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
|
25
|
Stress ulcer prophylaxis in the new millennium: A systematic review and meta-analysis. Crit Care Med 2010; 38:2222-8. [DOI: 10.1097/ccm.0b013e3181f17adf] [Citation(s) in RCA: 156] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
|
26
|
Amaral MC, Favas C, Alves JD, Riso N, Riscado MV. Stress-related mucosal disease: incidence of bleeding and the role of omeprazole in its prophylaxis. Eur J Intern Med 2010; 21:386-8. [PMID: 20816590 DOI: 10.1016/j.ejim.2010.06.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Revised: 06/12/2010] [Accepted: 06/17/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND Upper gastrointestinal bleeding is the severe complication of stress-related mucosal disease in hospitalized patients. In intensive care units (ICU), risk factors are well defined and only mechanical ventilation and coagulopathy proved to be relevant for significant bleeding. On the contrary, in non-ICU settings there is no consensus about this issue. Nevertheless, omeprazole is still widely used in prophylaxis of bleeding. The objective of our study was to evaluate the relevance of stress-related mucosal disease bleeding in patients admitted to an internal medicine ward, and the role of omeprazole in its prophylaxis. METHODS We conducted a retrospective study in which we analysed consecutive patients who were admitted to our ward over a year. We recorded demographic characteristics of the patients, potential risk factors for stress-related mucosal disease (clinical data, laboratory, and medication), administration of prophylactic omeprazole, and total cost of this prophylaxis. Patients with active gastrointestinal bleeding on the admission were excluded. We recorded every upper gastrointestinal bleeding event with clinical relevance. RESULTS Five hundred and thirty-five patients, mean age 70 years, mean length of stay 9.6+/-7.7 days; 140 (26.2%) patients were treated with 40 mg of omeprazole intravenously, 193 (36.1%) with 20mg of omeprazole orally, and 202 (37.8%) patients had no prophylaxis. There was only one episode (0.2%) of clinically relevant bleeding. CONCLUSION In patients admitted to an internal medicine ward, incidence of upper gastrointestinal bleeding as a complication of stress-related mucosal disease is low. We found that there is no advantage in prophylaxis with omeprazole.
Collapse
Affiliation(s)
- Marta C Amaral
- Department of Medicine II, Curry Cabral Hospital, and Pharmacology Department, Faculty of Medical Sciences, New University of Lisbon, Campo Mártires da Pátria 130, Lisbon, Portugal.
| | | | | | | | | |
Collapse
|
|
27
|
George AT, Tharyan P, Peter JV, Kirubakaran R, Barnabas JP. Interventions for preventing upper gastrointestinal bleeding in people admitted to intensive care units. Hippokratia 2010. [DOI: 10.1002/14651858.cd008687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Aneesh Thomas George
- Christian Medical College; South Asian Cochrane Network & Centre, Prof. BV Moses & ICMR Advanced Centre for Research & Training in Evidence Informed Health Care; Carman Block II Floor CMC Campus, Bagayam Vellore Tamil Nadu India 632002
| | - Prathap Tharyan
- Christian Medical College; South Asian Cochrane Network & Centre, Prof. BV Moses & ICMR Advanced Centre for Research & Training in Evidence Informed Health Care; Carman Block II Floor CMC Campus, Bagayam Vellore Tamil Nadu India 632002
| | - John V Peter
- Christian Medical College & Hospital; Medical Intensive Care Unit; Ida Scudder Road Vellore Tamil Nadu India 632004
| | - Richard Kirubakaran
- Christian Medical College; South Asian Cochrane Network & Centre, Prof. BV Moses & ICMR Advanced Centre for Research & Training in Evidence Informed Health Care; Carman Block II Floor CMC Campus, Bagayam Vellore Tamil Nadu India 632002
| | - Jabez Paul Barnabas
- Christian Medical College; South Asian Cochrane Network & Centre, Prof. BV Moses & ICMR Advanced Centre for Research & Training in Evidence Informed Health Care; Carman Block II Floor CMC Campus, Bagayam Vellore Tamil Nadu India 632002
| |
Collapse
|
|
28
|
Lin PC, Chang CH, Hsu PI, Tseng PL, Huang YB. The efficacy and safety of proton pump inhibitors vs histamine-2 receptor antagonists for stress ulcer bleeding prophylaxis among critical care patients: a meta-analysis. Crit Care Med 2010; 38:1197-1205. [PMID: 20173630 DOI: 10.1097/ccm.0b013e3181d69ccf] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To examine the efficacy and safety of proton pump inhibitors in comparison with histamine-2 receptor antagonists for stress-related upper gastrointestinal bleeding prophylaxis among critical care patients. DATA SOURCES PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov. STUDY SELECTION Randomized, controlled trials that directly compare proton pump inhibitors with histamine-2 receptor antagonists in prevention of stress-related upper gastrointestinal bleeding in intensive care unit patients published before May 30, 2008. DATA EXTRACTION Two reviewers independently applied selection criteria, performed quality assessment, and extracted data. The primary outcome was the incidence of stress-related upper gastrointestinal bleeding, and the secondary outcome measures were the incidence of pneumonia and intensive care unit mortality. DATA SYNTHESIS The random effect model was used to estimate the pooled risk difference between two treatment arms irrespective of drug, dosage, and route of administration. RESULTS We identified seven randomized, controlled trials with a total of 936 patients for planned comparison. The overall pooled risk difference (95% confidence interval; p value; I statistics) of stress-related upper gastrointestinal bleeding comparing proton pump inhibitors vs. histamine-2 receptor antagonists was -0.04 (95% confidence interval, -0.09-0.01; p = .08; I = 66%). In the sensitivity analysis, removing the Levy study significantly reduced the heterogeneity (from I = 66% to I = 26%) and shifted the overall risk difference closer to the null (pooled risk difference, -0.02; 95% confidence interval, -0.05-0.01; p = .19). There was no difference between proton pump inhibitors and histamine-2 receptor antagonists therapy in the risk of pneumonia and intensive care unit mortality, with pooled risk differences of 0.00 (95% confidence interval, -0.04-0.05; p = .86; I = 0%) and 0.02 (95% confidence interval, -0.04-0.08; p = .50; I = 0%), respectively. CONCLUSIONS This meta-analysis did not find strong evidence that proton pump inhibitors were different from histamine-2 receptor antagonists in terms of stress-related upper gastrointestinal bleeding prophylaxis, pneumonia, and mortality among patients admitted to intensive care units. Because of limited trial data, future well-designed and powerful randomized, clinical trials are warranted.
Collapse
Affiliation(s)
- Pei-Chin Lin
- Department of Pharmacy, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | | | | | | | | |
Collapse
|
|
29
|
Abstract
Clinical trials conducted in the latter part of the past millennium suggested that bleeding from gastric stress ulceration was an important cause of morbidity and mortality in intensive care unit (ICU) patients and that treatment with acid-suppressive therapy reduced the risk of clinically significant bleeding. Stress ulcer prophylaxis therefore became regarded as the standard of care in all ICU patients. However, more recent clinical trials have demonstrated that the risk of clinically significant bleeding is extremely low (about 1%) and not altered by the use of acid-suppressive therapy. Furthermore, a critical review of the “historical” clinical trials, as well as the data from experimental and more recent clinical trials, suggests that enteral feeding (gastric) is at least as effective as acid-suppressive therapy in the prevention of gastric stress ulceration and is the prophylactic measure of choice in most ICU patients.
Collapse
|
|
30
|
Laine L, Takeuchi K, Tarnawski A. Gastric mucosal defense and cytoprotection: bench to bedside. Gastroenterology 2008; 135:41-60. [PMID: 18549814 DOI: 10.1053/j.gastro.2008.05.030] [Citation(s) in RCA: 483] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Revised: 04/07/2008] [Accepted: 05/05/2008] [Indexed: 02/06/2023]
Abstract
The gastric mucosa maintains structural integrity and function despite continuous exposure to noxious factors, including 0.1 mol/L HCl and pepsin, that are capable of digesting tissue. Under normal conditions, mucosal integrity is maintained by defense mechanisms, which include preepithelial factors (mucus-bicarbonate-phospholipid "barrier"), an epithelial "barrier" (surface epithelial cells connected by tight junctions and generating bicarbonate, mucus, phospholipids, trefoil peptides, prostaglandins (PGs), and heat shock proteins), continuous cell renewal accomplished by proliferation of progenitor cells (regulated by growth factors, PGE(2) and survivin), continuous blood flow through mucosal microvessels, an endothelial "barrier," sensory innervation, and generation of PGs and nitric oxide. Mucosal injury may occur when noxious factors "overwhelm" an intact mucosal defense or when the mucosal defense is impaired. We review basic components of gastric mucosal defense and discuss conditions in which mucosal injury is directly related to impairment in mucosal defense, focusing on disorders with important clinical sequelae: nonsteroidal anti-inflammatory drug (NSAID)-associated injury, which is primarily related to inhibition of cyclooxygenase (COX)-mediated PG synthesis, and stress-related mucosal disease (SRMD), which occurs with local ischemia. The annual incidence of NSAID-associated upper gastrointestinal (GI) complications such as bleeding is approximately 1%-1.5%; and reductions in these complications have been demonstrated with misoprostol, proton pump inhibitors (PPIs) (only documented in high-risk patients), and COX-2 selective inhibitors. Clinically significant bleeding from SRMD is relatively uncommon with modern intensive care. Pharmacologic therapy with antisecretory drugs may be used in high-risk patients (eg, mechanical ventilation >or=48 hours), although the absolute risk reduction is small, and a decrease in mortality is not documented.
Collapse
Affiliation(s)
- Loren Laine
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
| | | | | |
Collapse
|
|
31
|
Comment on "Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008" by Dellinger et al. Intensive Care Med 2008; 34:1160-2; author reply 1163-4. [PMID: 18415078 PMCID: PMC2480487 DOI: 10.1007/s00134-008-1089-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2008] [Indexed: 01/04/2023]
|
|
32
|
Ojiako K, Shingala H, Schorr C, Gerber DR. Famotidine Versus Pantoprazole for Preventing Bleeding in the Upper Gastrointestinal Tract of Critically Ill Patients Receiving Mechanical Ventilation. Am J Crit Care 2008. [DOI: 10.4037/ajcc2008.17.2.142] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Mechanical ventilation increases risk for bleeding in the upper part of the gastrointestinal tract. Proton pump inhibitors, although they are more potent and longer acting inhibitors of gastric acid production than are histamine2 antagonists, also are generally more expensive. Data comparing the 2 types of agents for preventing gastrointestinal bleeding in critically ill patients are limited.
Objectives To compare the effectiveness of famotidine (a histamine2 antagonist) and pantoprazole (a proton pump inhibitor) in preventing stress ulcers in critically ill patients receiving mechanical ventilation.
Methods Data were collected from the Project Impact database. All patients who received mechanical ventilation for more than 48 hours from November 2002 to June 2006 and were treated with either drug were included. Patients receiving other drugs or with known bleeding in the upper part of the gastrointestinal tract, thrombocytopenia, or coagulopathy were excluded.
Results A total of 522 patients who received famotidine and 95 who received pantoprazole were included. Bleeding in the upper part of the gastrointestinal tract was more common in patients receiving pantoprazole than in patients receiving famotidine (0.38% vs 3.2%, P= .03). Although scores on the Acute Physiology and Chronic Health Evaluation II were higher in patients who received pantoprazole (P= .01), other outcome measures did not differ significantly between groups. Bleeding in the upper part of the gastrointestinal tract was more frequent among dialysis patients receiving pantoprazole than among those receiving famotidine.
Conclusions Famotidine and pantoprazole are similarly effective for preventing bleeding in the upper part of the gastrointestinal tract in patients receiving mechanical ventilation.
Collapse
Affiliation(s)
- Kizito Ojiako
- Kizito Ojiako is a fellow in critical care medicine, Hiren Shingala is a resident in internal medicine, Christa Schorr is a project impact administrative specialist, and David R. Gerber is associate director of the medical-surgical intensive care unit at Cooper University Hospital, Camden, New Jersey. Gerber is also an associate professor of medicine at the University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, in Camden
| | - Hiren Shingala
- Kizito Ojiako is a fellow in critical care medicine, Hiren Shingala is a resident in internal medicine, Christa Schorr is a project impact administrative specialist, and David R. Gerber is associate director of the medical-surgical intensive care unit at Cooper University Hospital, Camden, New Jersey. Gerber is also an associate professor of medicine at the University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, in Camden
| | - Christa Schorr
- Kizito Ojiako is a fellow in critical care medicine, Hiren Shingala is a resident in internal medicine, Christa Schorr is a project impact administrative specialist, and David R. Gerber is associate director of the medical-surgical intensive care unit at Cooper University Hospital, Camden, New Jersey. Gerber is also an associate professor of medicine at the University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, in Camden
| | - David R. Gerber
- Kizito Ojiako is a fellow in critical care medicine, Hiren Shingala is a resident in internal medicine, Christa Schorr is a project impact administrative specialist, and David R. Gerber is associate director of the medical-surgical intensive care unit at Cooper University Hospital, Camden, New Jersey. Gerber is also an associate professor of medicine at the University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, in Camden
| |
Collapse
|
|
33
|
Klebl FH, Schölmerich J. Therapy insight: Prophylaxis of stress-induced gastrointestinal bleeding in critically ill patients. ACTA ACUST UNITED AC 2007; 4:562-70. [PMID: 17909533 DOI: 10.1038/ncpgasthep0953] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2007] [Accepted: 08/06/2007] [Indexed: 12/15/2022]
Abstract
Stress-induced gastrointestinal bleeding is associated with increased morbidity and mortality in critically ill patients. Within the past few decades, the incidence of stress-induced gastrointestinal bleeding has decreased. Prophylaxis of stress-induced gastrointestinal bleeding, which is aimed at preventing morbidity and mortality, has to be achieved with as few adverse effects as possible. Data indicate that not all critically ill patients need prophylaxis for stress-induced gastrointestinal bleeding. The main risk factors associated with clinically important hemorrhage are mechanical ventilation for >48 h, and coagulopathy (thrombocyte count <50/nl, partial thromboplastin time (PTT) >2 times the upper limit of the normal range, international normalized ratio (INR) >1.5). Ranitidine is more effective than sucralfate for the prevention of clinically important bleeding. Immediate-release omeprazole is as effective as cimetidine, and is more efficient at increasing the intragastric pH. As yet, however, there is no firm evidence that any of the drugs used for prophylaxis of stress-induced gastrointestinal bleeding in critically ill patients decrease mortality or the length of hospital stay. When to stop prophylaxis is decided on clinical grounds rather than on the basis of data from clinical studies.
Collapse
Affiliation(s)
- Frank H Klebl
- Department of Internal Medicine I, University of Regensburg, Regensburg, Germany.
| | | |
Collapse
|
|
34
|
Kahn JM, Doctor JN, Rubenfeld GD. Stress ulcer prophylaxis in mechanically ventilated patients: integrating evidence and judgment using a decision analysis. Intensive Care Med 2006; 32:1151-8. [PMID: 16788804 DOI: 10.1007/s00134-006-0244-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2005] [Accepted: 05/18/2006] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Stress ulcer prophylaxis with a histamine-2 receptor antagonist can reduce the risk of gastrointestinal bleeding in mechanically ventilated patients but may also increase the risk of ventilator-associated pneumonia. We sought to clarify the tradeoffs involved in selecting a prophylactic strategy. DESIGN Decision analysis. PATIENTS AND PARTICIPANTS A decision tree was constructed for a hypothetical cohort of patients receiving mechanical ventilation for an expected duration of longer than 48 h, using probabilities estimated from the published literature. INTERVENTIONS Patients in the model could receive either prophylaxis with a histamine-2 receptor antagonist or no prophylaxis. Sensitivity analyses were preformed varying the estimated probabilities over their plausible ranges. MEASUREMENTS AND RESULTS Both strategies were associated with approximately the same baseline expected mortality (16.6% for histamine-2 receptor antagonists and 16.9% for no prophylaxis, risk difference 0.3%). Varying the estimated probabilities resulted in only small changes in both the expected mortality and the absolute risk reduction associated with the preferred treatment. At the extremes of assumptions the absolute mortality reduction ranged from 0.1% to 3.3%. CONCLUSIONS No single strategy of stress ulcer prophylaxis is preferred when mortality is used as the outcome. In the absence of a clinical trial demonstrating survival benefit the individual clinician's assumptions regarding the effect of prophylaxis on gastrointestinal bleeding and pneumonia and the attributable mortality of pneumonia vs. gastrointestinal bleeding will have a significant effect on the decision.
Collapse
Affiliation(s)
- Jeremy M Kahn
- Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98119, USA
| | | | | |
Collapse
|
|
35
|
Maury E, Tankovic J, Ebel A, Offenstadt G. An observational study of upper gastrointestinal bleeding in intensive care units: is Helicobacter pylori the culprit? Crit Care Med 2005; 33:1513-8. [PMID: 16003056 DOI: 10.1097/01.ccm.0000168043.60624.3e] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Upper gastrointestinal bleeding (UGIB) related to stress ulcers was formerly a fearsome complication of intensive care. The incidence of this event has decreased over the years. However, the morbidity, mortality, and causes of UGIB, particularly the etiologic role of Helicobacter pylori infection, are still controversial. Therefore, we prospectively assessed the incidence of UGIB in the intensive care unit (ICU) and evaluated the role of H. pylori infection. DESIGN A prospective observational study followed by a case-control study. SETTING Seven ICUs in the Paris area, five of them located in teaching hospitals. PATIENTS All patients admitted consecutively to seven ICUs during a 1-year period were monitored for signs of clinically relevant UGIB. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Only cases of endoscopically confirmed UGIB were analyzed. Patients whose hemorrhage originated from the stomach and/or duodenum were tested for H. pylori infection, by means of serology, histologic examination, and stool antigen detection. The possible association between H. pylori and UGIB was examined in a case-control study. Twenty-nine of the 4,341 patients admitted to the seven ICUs during the study period had clinically relevant, endoscopically confirmed UGIB (incidence, 0.67%; 95% confidence interval, 0.56%-0.77%). Ulcers were most frequently observed endoscopically. Patients who bled had a higher Simplified Acute Physiology Score (SAPS II) at admission (mean +/- sd, 47 +/- 14 vs. 36 +/- 28; p < .001). Despite a higher in-ICU mortality rate among patients who bled (73% vs. 16%; p < .001), death was never due to bleeding. H. pylori infection was more frequent in patients who bled than in matched controls (36% vs. 16%; p = .04). CONCLUSIONS Clinically relevant, endoscopically confirmed UGIB is a rare event in the ICU setting and tends to occur in severely ill patients. H. pylori infection is more frequent in patients with gastroduodenal hemorrhage than in nonbleeding patients.
Collapse
Affiliation(s)
- Eric Maury
- Service de Réanimation Médicale, Unité Inserm U444, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | | | | |
Collapse
|
|
36
|
|
|
37
|
Abstract
OBJECTIVE In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for other supportive therapies in sepsis that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis. DESIGN The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. METHODS The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591. CONCLUSION Patients with severe sepsis should be treated with deep-vein thrombosis prophylaxis. Low-dose unfractionated heparin or low molecular weight heparin is preferred. Use of graduated compression devices is recommended in septic patients with contraindication to the use of heparin or combined with heparin in very high-risk patients. Stress ulcer prophylaxis should be given to all patients with severe sepsis. Histamine-2 receptor antagonists are more effective than sucralfate in decreasing bleeding risk and transfusion requirements. Proton pump inhibitors have not been assessed in a direct comparison with histamine-2 receptor antagonists but do demonstrate equivalency and ability to increase gastric pH.
Collapse
Affiliation(s)
- Stephen Trzeciak
- UMDNJ-Robert Wood Johnson Medical School at Camden, Camden, NJ, USA
| | | |
Collapse
|
|
38
|
Faisy C, Guerot E, Diehl JL, Iftimovici E, Fagon JY. Clinically significant gastrointestinal bleeding in critically ill patients with and without stress-ulcer prophylaxis. Intensive Care Med 2003; 29:1306-13. [PMID: 12830375 DOI: 10.1007/s00134-003-1863-3] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2002] [Accepted: 05/15/2003] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To compare the rates of clinically significant gastrointestinal bleeding and the number of blood units and endoscopies required for gastrointestinal hemorrhage between patients receiving or not receiving stress-ulcer prophylaxis. DESIGN Historical observational study comparing two consecutive periods: with (phase 1) and without stress-ulcer prophylaxis (phase 2). DESIGN AND SETTING A 17-bed intensive care unit in a university teaching hospital. PATIENTS. In phase 1 there were 736 patients and in phase 2737. Those in the two phases were comparable in age and reason for admission; clinically significant gastrointestinal bleeding rates did not differ between the two phases, but patients in phase 2 were more severely ill. MEASUREMENTS AND RESULTS Comparable numbers of blood units were transfused per bleeding patient in the two phases, especially for patients with significant gastrointestinal bleeding. During each phase 19 fibroscopies were performed for significant bleeding, and two patients required surgery. The clinically significant gastrointestinal bleeding rate and outcome did not differ in patients with at least one risk factor. Total expenditures directly related to gastrointestinal bleeding were similar during the two phases; the total cost incurred by stress-ulcer prophylaxis was estimated at 6700. CONCLUSIONS Our results suggest that stress-ulcer prophylaxis does not influence the clinically significant gastrointestinal bleeding rate in intensive care unit patients or the cost of its management.
Collapse
Affiliation(s)
- Christophe Faisy
- Service de Réanimation Médicale, Hôpital Européen Georges-Pompidou, 20 rue Leblanc, 75908, Paris Cedex 15, France
| | | | | | | | | |
Collapse
|
|
39
|
Abstract
Stress-related mucosal disease is common in critically ill patients and can result in significant morbidity. The pathophysiology of this condition is multifactorial but mucosal ischaemia and gastric acid have pivotal roles. The major risk factors for developing stress-related mucosal bleeding are prolonged mechanical ventilation and coagulopathy. The mainstay of clinical management is prevention with acid-suppressing medications and cytoprotective agents. This chapter discusses medications used to prevent this condition and suggests an approach for management. Recent developments in gastroenterology include the development and use of proton pump inhibitors and the discovery of the association Helicobacter pylori with gastritis. The role of each of these in stress-related mucosal disease is discussed. Finally, an approach to the bleeding critically ill patient is presented.
Collapse
Affiliation(s)
- Donald R Duerksen
- Division of Gastroenterology, Department of Medicine, St Bonfaice Hospital, C5 120 409 Tache Avenue, Winnipeg, Man., Canada R2H 2A6.
| |
Collapse
|
|
40
|
Spirt MJ. Stress-related Mucosal Disease. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2003; 6:135-145. [PMID: 12628072 DOI: 10.1007/s11938-003-0014-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Stress-related mucosal disease (SRMD) includes stress-related injury (superficial mucosal damage) and stress ulcers (focal deep mucosal damage). Both types are caused by mucosal ischemia, and both show a propensity for the acid-producing corpus and fundus. Prophylaxis of stress ulcers may reduce major bleeding but, so far, has not been shown to improve survival. The most widely used drugs for stress-related injury are the intravenous histamine H(2)-receptor antagonists. Proton pump inhibitors (PPIs) are the most potent acid-suppressive pharmacologic agents. The available PPIs significantly increase gastric pH for up to 24 hours after one dose. Tolerance does not develop, and adverse effects are few. Preliminary studies have demonstrated a significant reduction in SRMD bleeding for patients receiving PPI prophylaxis. PPIs may become an effective tool for reducing the incidence of SRMD in critically ill patients.
Collapse
|
|
41
|
van der Voort PH, van der Hulst RW, Zandstra DF, Geraedts AA, van der Ende A, Tytgat GN. Suppression of Helicobacter pylori infection during intensive care stay: related to stress ulcer bleeding incidence? J Crit Care 2001; 16:182-7. [PMID: 11815904 DOI: 10.1053/jcrc.2001.30164] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To assess the prevalence of active Helicobacter pylori infection in patients admitted to the intensive care unit, to determine the effect of selective gut decontamination on the persistence of this organism, and to explore the possible relationship between H. pylori infection and stress ulcer bleeding incidence. MATERIALS AND METHODS We determined in a prospective observational study of 300 consecutive, mechanically ventilated patients the activity of H. pylori infection and the incidence of stress ulcer-related upper gastrointestinal bleeding over time. H. pylori infection was detected by Laser-Assisted Ratio Analyzer (LARA)- (13)C-urea breath test (Alimenterics, Inc., NJ) and serology. Stress ulcer prophylaxis was not prescribed. Endoscopy was performed in cases of upper gastrointestinal bleeding. RESULTS The prevalence of active H. pylori infection on admission was 38% as detected by urea breath test, and declined to 8% on the third day, and to 0% on the seventh day after admission as a result of antibiotic treatment. Stress ulcer-related upper gastrointestinal bleeding occurred in 1.0% (3 of 300) of the patients; none were infected with H. pylori on admission or at the time of bleeding. CONCLUSIONS H. pylori infection monitored by LARA- (13)C-urea breath test was rapidly suppressed during intensive care treatment, which can be explained by the routine use of antibiotics for gut decontamination.The low incidence of stress ulcer-related bleeding might be related to the prevention of H. pylori-associated stress lesions by effective suppression of this microorganism, but further studies are warranted to test this hypothesis.
Collapse
Affiliation(s)
- P H van der Voort
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | | | | | | | | |
Collapse
|
|
42
|
MacLaren R, Jarvis CL, Fish DN. Use of enteral nutrition for stress ulcer prophylaxis. Ann Pharmacother 2001; 35:1614-23. [PMID: 11793631 DOI: 10.1345/aph.1a083] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To review the controversies involving the use of enteral nutrition support for stress ulcer prophylaxis and formulate recommendations. DATA SOURCES A MEDLINE search (1966-December 2000) was conducted using the MeSH of nutrition, ulcer, critical care, and acid to identify relevant articles. References of selected articles were reviewed, and relevant abstracts from critical care or gastrointestinal journals identified. DATA EXTRACTION Animal and human data from prospective studies, retrospective studies, and case series were evaluated for the effects of enteral nutrition on gastric pH, intramucosal pH, gastrointestinal blood flow, development of macroscopic mucosal erosions, and hemorrhage. DATA SYNTHESIS Intragastric administration of enteral nutrition has variable effects on gastric pH, enhances regional distribution of gastrointestinal blood flow, and may lower intramucosal pH. All substrates (carbohydrate, lipid, amino acid), when administered into the stomach, reduce the occurrence of mucosal erosions but do not entirely prevent their development. Few studies of stress ulcer prophylaxis regimens have reported use of enteral nutrition. Limited retrospective data suggest enteral nutrition support may be effective for preventing gastrointestinal hemorrhage, but the results of prospective studies are confounded by poor study design. CONCLUSIONS Definitive recommendations regarding the role of enteral nutrition for stress ulcer prophylaxis are not possible due to the lack of prospective, randomized studies. Therefore, the use of enteral nutrition as the only therapeutic agent for stress ulcer prophylaxis should be discouraged until definitive data are available. Initiation and discontinuation of pharmacologic stress ulcer prophylaxis should be independent of enteral nutrition.
Collapse
Affiliation(s)
- R MacLaren
- School of Pharmacy, C238, University of Colorado Health Sciences Center, 4200 E. Ninth Ave., Denver, CO 80262-0001, USA.
| | | | | |
Collapse
|
|
43
|
Zarzaur BL, Kudsk KA, Carter K, Pritchard FE, Fabian TC, Croce MA, Minard G. Stress Ulceration Requiring Definitive Surgery after Severe Trauma. Am Surg 2001. [DOI: 10.1177/000313480106700913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite antiulcer prophylaxis 19 severely injured patients at our institution developed stress ulceration (SU) between 1989 and 1999 requiring surgery for perforation (n = 4) or bleeding (n = 15). A herald bleed (HB) 10.7 ± 1.2 days after admission, 7.2 ± 1.2 days before definitive operative therapy, and requiring 7.1 ± 0.9 units of blood occurred in 93 per cent of patients operated on for bleeding. Bleeding preceded perforation in one patient. Central nervous system damage was part of the injury pattern in 68 per cent of the patients including spinal cord (42%), severe head injury (16%), or both (10%). Forty-two per cent had acalculous cholecystitis found at surgery. Eight patients had vagotomy and antrectomy (VA), and 11 patients had vagotomy and pyloroplasty (VP). VA required more time than VP (255 ± 41 vs 158 ± 13 minutes; P = 0.02). One patient (12.5%) rebled after VA versus two (18%) after VP; one patient in each group required reoperation. There was no difference in mortality, length of stay, or intensive care unit stay. A herald bleed preceded recurrent hemorrhage of SU by one week. Spinal cord or head injury increase the risk of SU. More than 40 per cent of patients with SU had acalculous cholecystitis found at operation. VA provides no benefit on rebleeding or reoperation over VP, so anatomical considerations and not rebleed rates should determine the surgical procedure.
Collapse
Affiliation(s)
- Ben L. Zarzaur
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kenneth A. Kudsk
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Katrina Carter
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - F. Elizabeth Pritchard
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Timothy C. Fabian
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Martin A. Croce
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Gayle Minard
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, Tennessee
| |
Collapse
|
|
44
|
Abstract
Mechanical ventilation (MV) can be lifesaving by maintaining gas exchange until the underlying disorders are corrected, but it is associated with numerous organ-system complications, which can significantly affect the outcome of critically ill patients. Like other organ systems, GI complications may be directly attributable to MV, but most are a reflection of the severity of the underlying disease that required intensive care. The interactions of the underlying critical illness and MV with the GI tract are complex and can manifest in a variety of clinical pictures. Incorporated in this review are discussions of the most prevalent GI complications associated with MV, and current diagnosis and management of these problems.
Collapse
Affiliation(s)
- G M Mutlu
- Section of Respiratory and Critical Care Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | | | | |
Collapse
|
|
45
|
Abstract
In summary, a variety of gastrointestinal processes may occur in the chronically critically ill patient population, usually as consequence of the primary systemic process. The clinical presentation is frequently nonclassic and there often is a substantial delay in diagnosis, resulting in increased morbidity and mortality.
Collapse
Affiliation(s)
- S G Sheth
- Haryard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | |
Collapse
|
|
46
|
Cook DJ, Griffith LE, Walter SD, Guyatt GH, Meade MO, Heyland DK, Kirby A, Tryba M. The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients. Crit Care 2001; 5:368-75. [PMID: 11737927 PMCID: PMC83859 DOI: 10.1186/cc1071] [Citation(s) in RCA: 212] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2001] [Revised: 09/08/2001] [Accepted: 09/20/2001] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To estimate the mortality and length of stay in the intensive care unit (ICU) attributable to clinically important gastrointestinal bleeding in mechanically ventilated critically ill patients. DESIGN Three strategies were used to estimate the mortality attributable to bleeding in two multicentre databases. The first method matched patients who bled with those who did not (matched cohort), using duration of ICU stay prior to the bleed, each of six domains of the Multiple Organ Dysfunction Score (MODS) measured 3 days prior to the bleed, APACHE II score, age, admitting diagnosis, and duration of mechanical ventilation. The second approach employed Cox proportional hazards regression to match bleeding and non-bleeding patients (model-based matched cohort). The third method, instead of matching, derived estimates based on regression modelling using the entire population (regression method). Three parallel analyses were conducted for the length of ICU stay attributable to clinically important bleeding. SETTING Sixteen Canadian university-affiliated ICUs. PATIENTS A total of 1666 critically ill patients receiving mechanical ventilation for at least 48 hours. MEASUREMENTS We prospectively collected data on patient demographics, APACHE II score, admitting diagnosis, daily MODS, clinically important bleeding, length of ICU stay, and mortality. Independent adjudicators determined the occurrence of clinically important gastrointestinal bleeding, defined as overt bleeding in association with haemodynamic compromise or blood transfusion. RESULTS Of 1666 patients, 59 developed clinically important gastrointestinal bleeding. The mean APACHE II score was 22.9 +/- 8.6 among bleeding patients and 23.3 +/- 7.7 among non-bleeding patients. The risk of death was increased in patients with bleeding using all three analytic approaches (matched cohort method: relative risk [RR]= 2.9, 95% confidence interval (CI)= 1.6-5.5; model-based matched cohort method: RR = 1.8, 95% CI = 1.1-2.9; and the regression method: RR = 4.1, 95% CI = 2.6-6.5). However, this was not significant for the adjusted regression method (RR = 1.0, 95% CI = 0.6-1.7). The median length of ICU stay attributable to clinically important bleeding for these three methods, respectively, was 3.8 days (95% CI = -0.01 to 7.6 days), 6.7 days (95% CI = 2.7-10.7 days), and 7.9 days (95% CI = 1.4-14.4 days). CONCLUSIONS Clinically important upper gastrointestinal bleeding has an important attributable morbidity and mortality, associated with a RR of death of 1-4 and an excess length of ICU stay of approximately 4-8 days.
Collapse
Affiliation(s)
- D J Cook
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
| | | | | | | | | | | | | | | |
Collapse
|
|
47
|
Beejay U, Wolfe MM. Acute gastrointestinal bleeding in the intensive care unit. The gastroenterologist's perspective. Gastroenterol Clin North Am 2000; 29:309-36. [PMID: 10836185 DOI: 10.1016/s0889-8553(05)70118-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Although SRES-associated hemorrhage previously constituted a significant cause of bleeding in the ICU, improvements in ICU management and the institution of prophylactic measures in high-risk patients have significantly reduced SRES-associated hemorrhage since the 1980s. Antacids, H2-receptor antagonists, and sucralfate have been shown to be effective in preventing clinically significant bleeding resulting from SRES, particularly when the intragastric pH is maintained at greater than 4. A selective approach should be adopted in SRES prophylaxis: Patients on mechanical ventilation, with coagulopathy, or with two of the other known risk factors should receive prophylaxis. Although the drug of choice depends to some extent on local preferences, an H2-receptor antagonist by continuous intravenous infusion may represent the best option. No pharmacologic therapy is of proven value once hemorrhage begins, but the current interventional techniques are effective in controlling hemorrhage. Gastrointestinal bleeding from NOMV has become less common with improvements in the hemodynamic monitoring of critically ill patients, but this disease must always be considered when lower gastrointestinal bleeding occurs in the context of relative hypoperfusion. For SRES and NOMV, treatment of the underlying disease or diseases is the optimal route to prevention.
Collapse
Affiliation(s)
- U Beejay
- Section of Gastroenterology, Boston University School of Medicine, Massachusetts, USA
| | | |
Collapse
|
|
48
|
van der Voort PH, Zandstra DF. Pathogenesis, risk factors, and incidence of upper gastrointestinal bleeding after cardiac surgery: Is specific prophylaxis in routine bypass procedures needed? J Cardiothorac Vasc Anesth 2000. [DOI: 10.1053/cr.2000.5849] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
|
49
|
Zhu L, Yang ZC, Li A, Cheng DC. Reduced gastric acid production in burn shock period and its significance in the prevention and treatment of acute gastric mucosal lesions. World J Gastroenterol 2000; 6:84-88. [PMID: 11819529 PMCID: PMC4723604 DOI: 10.3748/wjg.v6.i1.84] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the changes of gastric acid production and its mechanism in shock period of severe burn in rats.
METHODS: A rat model with 30% TBSA full-thickness burn injury w as employed and the gastric acid production, together with gastric mucosal blood flow (GMBF) and energy charge (EC) were measured serially within 48 h postburn.
RESULTS: The gastric acid production in the acute shock period was markedly inhibited after severe burn injury. At the 3rd h postburn, the gas tricjuice volume, total acidity and acid output were already significantly decreased (P < 0.01), and reached the lowest point, 0.63 mL/L ± 0.20 mL/L, 10.81 mmol/L ± 2.58 mmol/L and 2.23 mmol/h ± 0.73 mmol/h respectively, at the 12th h postburn. Although restored to some degree 24 h after thermal injury, the variables above were still statistically lower, compared with those of control animals at the 48th h postburn. The GMBF and EC were also significantly reduced after severe burns, co nsistent with the trend of gastric acid production changes.
CONCLUSION: Gastric acid production, as well as GMBF and EC was predominantly decreased in the early postburn stage, suggesting that gastric mucosal ischemia and hypoxia with resultant disturbance in energy metabolism, but not gastric acid proper, might be the decisive factor in the pathogenesis of AGML after thermal injury, and that the preventive use of anti-acid drugs during burn shock period was unreasonable in some respects. Therefore, taking effective measures to improve gastric mucosal blood perfusion as early as possible postburn might be more preferable for the AGML prevention and treatment.
Collapse
|
|
50
|
Brundage SI, Maier RV. Trauma intensive care. TRAUMA-ENGLAND 2000. [DOI: 10.1177/146040860000200103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Management of the traumatically injured patient in the intensive care unit is a complex and challenging area of general surgery. The problems encountered in the intensive care unit are the source of exciting clinical and basic science research. The future of caring for the severely injured patient suffering from the complications of trauma will undoubtedly further bond the art of clinical medicine to the accomplishments of developing technology and molecular biology.
Collapse
Affiliation(s)
- Susan I Brundage
- Surgical Emergency Center Services, Department of Surgery, Baylor College of Medicine, Ben Taub General Hospital, Houston, Texas, USA
| | - Ronald V Maier
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| |
Collapse
|