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Abstract
BackgroundPharmacologic 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.MethodsWe 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.ResultsSeven 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).ConclusionsOur results suggested that in patients receiving enteral feeding, pharmacologic SUP is not beneficial and combined interventions may even increase the risk of nosocomial pneumonia.
Highlights
Pharmacologic stress ulcer prophylaxis (SUP) is recommended in critically ill patients with high risk of stress-related gastrointestinal (GI) bleeding
Open-label trial, continuous enteral nutrition (EN) was shown more likely than proton pump inhibitors (PPIs) or histamine 2 receptor antagonists (H2RAs) to raise gastric pH to above 3.5, suggesting that EN might be more effective in preventing GI bleeding than pharmacologic SUP [17]
These findings were based on an evaluation of only 262 patients in three randomized controlled trials (RCTs), which were published between the years 1985 and 1994 and compared H2RAs with placebo [21,22,23]
Summary
Pharmacologic stress ulcer prophylaxis (SUP) is recommended in critically ill patients with high risk of stress-related gastrointestinal (GI) bleeding. 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. In 2010, one meta-analysis comparing H2RAs to placebo or no prophylaxis for SUP looked into a subgroup of enterally fed patients In this subgroup, SUP did not decrease the risk of bleeding, and in contrast led to more episodes of hospital-acquired pneumonia (HAP) and higher mortality rate [4]. SUP did not decrease the risk of bleeding, and in contrast led to more episodes of hospital-acquired pneumonia (HAP) and higher mortality rate [4] These findings were based on an evaluation of only 262 patients in three randomized controlled trials (RCTs) (three trials in GI bleeding, two trials in HAP and mortality), which were published between the years 1985 and 1994 and compared H2RAs with placebo [21,22,23]. Two out of the three RCTs were unblinded [21, 22], and some of potentially important outcomes to clinicians or patients, including duration of mechanical ventilation, incidence of C. difficile infection, ventilatorassociated pneumonia (VAP) and length of ICU stay were not considered in this meta-analysis
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