Gastrointestinal Stress Ulcer Research Articles

Preliminary discussion on the prevention and treatment of shock after severe burns

Shock is one of the most common complications and one of the main causes of death after severe burns. The prevention and treatment of shock runs through the whole process of severe burn treatment. Shocks after severe burns, based on their causes, are mainly classified as follows: hypovolemic shock characterized by elevated hematocrit, also known as burn shock, and caused by serious leakage of intravascular fluid to body surface and interstitial spaces in the early stage of burns; hemorrhagic shock caused by large scale of incision and tension reduction, gastrointestinal stress ulcer, or large area of escharectomy and tangential excision surgery; septic shock caused by various microbial invasion; anaphylactic shock caused by infusion of drugs or blood. From the perspective of the reduction of effective circulating volume, burn shock and hemorrhagic shock are hypovolemic shocks, and septic shock and anaphylactic shock are vasodilatory shocks. As the aforementioned shocks vary in terms of occurrence timing, occurrence mechanism, and clinical manifestations, individualized strategies should be adopted for the prevention and treatment.

1210 Implementation of Stress Ulcer Prophylaxis Appropriate Use Criteria in a Community Hospital

INTRODUCTION: Upper gastrointestinal stress ulcer formation is a potential risk for critically ill hospitalized patients. Due to this, SUP is an important preventative measure for at risk patients. Stress ulcer medications such as PPIs and H2 blockers do come with potential side effects.1,2 A widely accepted guideline was written by the American Society of Health System Pharmacists which along with similar variations continue to be used today.3,4 One such guideline has been implemented within the Ascension Health System (Figure 1). Despite guidelines, inappropriate administration continues to be a common problem. Studies show rates of inappropriate administration anywhere from 20 to 70 percent.5–9 A discrepancy in knowledge from providers leads to inappropriate prescribing of SUP medications. Administration of these laminated cards will improve appropriate administration of the medications. METHODS: Laminated cards were dispersed to fit on ID badges of IM and FP residents which following the Ascension SUP guidelines. Data was collected on all patients admitted under the core faculty of an IM or FP attending between 7/1/18–9/30/18 and 11/1/18–1/31/19. 10/1/19-10/31/19 constituted the run-in period. Patients were excluded if they had active diagnoses of GERD, PUD, H. Pylori. Eligible patients' charts were reviewed at random by using an online number generator. The A&P section of the H&P note was reviewed to determine if SUP was was appropriately administered, appropriately held, inappropriately administered, or inappropriately held. Any discrepancies were reviewed by the principal investigator. A t-test was performed to determine if statistical significance was achieved. RESULTS: There were 124 and 115 patients in the pre and post-intervention period respectively. There was an overall improvement of 5.64% (P = 0.21) after distribution of cards (Figure 1). Inappropriately given SUP use improved by 5.01% (P = 0.22). Inappropriately held SUP use improved by 0.61% (P = 0.78). CONCLUSION: Administration of cards improved appropriate prescribing. The cards provided a resource to aid in enhancing knowledge and on-the-go decision making. The availability of implementing these guidelines or similar such protocols using EMR may be more effective in reaching a wider audience of physicians and provide a consistent effect on prescribing habits.

AB121. 75. The use of proton pump inhibitors in hip fracture patients

Background: Hip fractures represent a significant burden to every orthopaedic department. Patients with hip fractures are at risk of gastrointestinal stress ulceration. It is not common practice to prescribe prophylactic proton pump inhibitors (PPIs) to patients who are admitted with hip fractures. This may lead to an increased morbidity associated with gastrointestinal stress ulceration in this patient population.

Review and forecast of critical care medicine in 2018

In 2018, a bunch of considerable positive progresses have been presented, including a revised "hour-1 bundle" introduced by international guideline for management of sepsis and septic shock, trans-pulmonary pressure monitoring via esophageal manometry in acute respiratory distress syndrome (ARDS) models, successful trials for new antibiotics, angiotensin II in patients with vasodilatory shock and renal replacement therapy, advanced airway management in out-of-hospital cardiac arrest (OHCA) patients as well cellular immunotherapy for septic shock. But some of investigational trials did not yield expected results. For example, extracorporeal membrane oxygenation (ECMO) therapy for ARDS patients, the strategy of sequencing weaning with early extubation to noninvasive ventilation, prevention of delirium with haloperidol, surrogate decision supported by interprofessional intensive care unit (ICU) team and prophylaxis for gastrointestinal stress ulceration with pantoprazole in ICU. And more importantly, it has been obvious that the voices and evidences gathered by the opponents against guidelines development, compulsory polices of implementing bundled strategy, market position of hydroxyethyl-starch solutions (HES) and the usage of steroid in septic shock have been largely strengthen, highlighting a more divided and controversial situation.

Pantoprazole in Patients at Risk for Gastrointestinal Bleeding in the ICU

BackgroundProphylaxis for gastrointestinal stress ulceration is frequently given to patients in the intensive care unit (ICU), but its risks and benefits are unclear.MethodsIn this European, multicenter, parallel-group, blinded trial, we randomly assigned adults who had been admitted to the ICU for an acute condition (i.e., an unplanned admission) and who were at risk for gastrointestinal bleeding to receive 40 mg of intravenous pantoprazole (a proton-pump inhibitor) or placebo daily during the ICU stay. The primary outcome was death by 90 days after randomization.ResultsA total of 3298 patients were enrolled; 1645 were randomly assigned to the pantoprazole group and 1653 to the placebo group. Data on the primary outcome were available for 3282 patients (99.5%). At 90 days, 510 patients (31.1%) in the pantoprazole group and 499 (30.4%) in the placebo group had died (relative risk, 1.02; 95% confidence interval [CI], 0.91 to 1.13; P=0.76). During the ICU stay, at least one clinically important event (a composite of clinically important gastrointestinal bleeding, pneumonia, Clostridium difficile infection, or myocardial ischemia) had occurred in 21.9% of patients assigned to pantoprazole and 22.6% of those assigned to placebo (relative risk, 0.96; 95% CI, 0.83 to 1.11). In the pantoprazole group, 2.5% of patients had clinically important gastrointestinal bleeding, as compared with 4.2% in the placebo group. The number of patients with infections or serious adverse reactions and the percentage of days alive without life support within 90 days were similar in the two groups.ConclusionsAmong adult patients in the ICU who were at risk for gastrointestinal bleeding, mortality at 90 days and the number of clinically important events were similar in those assigned to pantoprazole and those assigned to placebo. (Funded by Innovation Fund Denmark and others; SUP-ICU ClinicalTrials.gov number, NCT02467621.)

AB223. 196. The use of proton pump inhibitors in hip fracture patients

Background: Hip fractures represent a significant burden to every Orthopaedic department. Patients with hip fractures are at risk of gastrointestinal stress ulceration. In other specialities prophylactic proton pump inhibitors (PPIs) are used to reduce the associated morbidity. It is not common practice to prescribe prophylactic PPIs to patients who are admitted with hip fractures. This may lead to an increased morbidity associated with gastrointestinal stress ulceration in this patient population.

Prophylactic proton pump inhibitors in femoral neck fracture patients - A life - and cost-saving intervention.

Introduction Acute gastrointestinal stress ulceration is a common and serious complication of trauma. Prophylactic proton pump inhibitors (PPIs) or histamine receptor antagonists have been used in poly-trauma, burns and head and spinal injuries, as well as on intensive care units, for the prevention of acute gastric stress ulcers. Methods We prospectively studied the use of prophylactic PPIs in with femoral neck fracture patients, gathering data on all acute gastric ulcer complications, including coffee-ground vomiting, malena and haematemesis. We then implemented a treatment protocol in which all patients were given prophylactic PPIs, again prospectively collecting all data. Results Five hundred and fifteen patients were included. Prior to prophylactic PPI, 15% of patients developed gastric stress ulcer complications, with 3% requiring acute intervention with oesophagogastroduodenoscopy (OGD), 5% requiring transfusions and 4% experiencing surgical delays. All patients had delayed discharges. Following PPI implementation, no patients developed gastric stress ulcer complications. Conclusions Femoral neck fracture patients create a substantial workload for orthopaedic units. The increasingly elderly population often have comorbidities, and concomitantly use medications with gastrointestinal side effects. This, combined with the stress of a fracture and preoperative starvation periods increases the risk of gastric ulcers. Here, the use of prophylactic PPIs statistically reduced the incidence of gastric stress ulcers in patients with femoral neck fractures, resulting in fewer surgical delays, reduced length of hospital stay and reduced stress ulcer-related mortality.

What is the best medicine for gastrointestinal stress ulcer prophylaxis in the critically ill patient?

Evidence-Based Answer There appears to be little difference in effectiveness between enteric proton-pump inhibitors and intravenous H2 blockers for the prevention of stress ulcers in critically ill hospitalized patients (SOR: B, heterogeneous RCTs). In addition, sucralfate appears to be as equally effective as IV ranitidine (SOR: B, single RCT).

Stress Ulcer Prophylaxis in the ICU: PPIs or H

Gastrointestinal stress ulceration occurs commonly in critically ill patients. Clinically important bleeding occurs in 1% to 4% of such cases and is

Application of recombinant human growth hormone combined with early enteral nutrition in severely burned patients

Objective To summarize the therapeutic effect of recombinant human growth hormone and early enteral nutrition in severely burned patients. Methods 35 cases were randomly divided into group EN and group PN.Group EN was treated with early enteral nutrition(EEN) and recombiant human growth hormone(rhGH) ,while group PN was given parenteral nutrition. The plasma levels of pre-albumin (PA), C-reactive protein (CRP) , tunmor necrosis factor α(TNFα) ,fasting blood glucose(FBG) were measured after burn injury. Comparision was made in length of hospital stay, wound healing time,incidence of burn sepsis, gastrointestinal stress ulcer bleeding and enteral nutrition intoleranc. Results Incidence of burn sepsis,gastrointestinal stress ulcer bleeding and enteral nutrition intoleranc in group EN were significantly lower than those of group PN(P ＜ 0.05). The serum levels of CRP、TNFα、FBG in group EN were significantly lower than those of group PN (P ＜ 0.05). The serum PA was decreased at all times in two periods and was markedly decreased in group EN(P ＜0.05). Length of hospital stay and the healing time of donor site, deep partial thickness burn wound, skin transplantion area were significantly shortened in group EN compared with group PN. Conclusion Early enteral nutrition was beneficial for the improving of nutrition state of the burn patients,and the reduction of the incidence of burn sepsis and the hospitalization time. Key words: Burn; Early enteral nutrition; Recombinant human growth hormone; Burn sepsis

Stress Ulcer Prophylaxis in the ICU: How Much Is Enough?

Stress ulcers of the gastrointestinal mucosa have been shown to develop in nearly all types of critically ill patients and endoscopic studies have shown mucosal abnormalities in the majority of patients [1]. As pointed out by Dr Marik in his article in this issue of the Journal of Intensive Care Medicine, the majority of patients do not manifest clinically important bleeding from gastrointestinal stress ulceration [2]. In fact, the incidence of clinically important bleeding from stress ulcers appears to have declined in recent years [3].