Received Stress Ulcer Prophylaxis Research Articles

Proton Pump Inhibitors Versus Histamine-2 Receptor Blockers for Stress Ulcer Prophylaxis on In-hospital Mortality Among Intensive Care Unit Patients Hospitalized for Major Adverse Cardiovascular and Cerebrovascular Events: Retrospective Cohort Study

Purpose: Patients in the Intensive Care Unit (ICU) commonly receive stress ulcer prophylaxis drugs, either Proton Pump Inhibitors (PPIs) or Histamine-2 Receptor Blockers (H2RBs). The goal of this research was to evaluate the impact of these drugs on mortality among ICU patients hospitalized for major adverse cardiovascular and cerebrovascular events (MACCEs). Methods: ICU Patients hospitalized for MACCEs were sourced from the Medical Information Mart for Intensive Care(MIMIC)-III database. We performed a propensity score (PS) matching analysis to match patients treated with PPIs to those with H2RBs for stress ulcer prophylaxis. The outcome was 90-day mortality. We utilized multivariable Cox regression analyses to compare the effect. Hazard ratio (HR), 95% confidence intervals, and P-values were reported from the model. Results: From 2001 to 2012, a total of 3577 patients hospitalized for MACCEs(1997 received PPIs and 1580 received H2RBs)were admitted. The 90-day mortality was 23.7% (848/3577); it was 27%(540/1997) and 19.5%(308/1580) for PPIs and H2RBs users, respectively. The PPI group exhibited a greater 90‑day mortality in comparison to the H2RBs group (relative risk: 1.17; P = 0.036), after conditioning on potential confounder. The results remained robust in propensity score matching, sensitivity analyses, and subgroup analyses. Conclusion: PPIs for stress ulcer prophylaxis was linked to an increased risk of in-hospital mortality than H2RBs in patients hospitalized for MACCEs. Further investigation this association is needed and validate whose clinical significance.

S1365 Inappropriate Continuation of Proton Pump Inhibitors Upon Discharge in Patients Who Received Stress Ulcer Prophylaxis

S1365 Inappropriate Continuation of Proton Pump Inhibitors Upon Discharge in Patients Who Received Stress Ulcer Prophylaxis

Reassessing the Use of Proton Pump Inhibitors and Histamine-2 Antagonists in Critically Ill Children: A Systematic Review and Meta-Analysis

To determine the associations of stress ulcer prophylaxis with gastrointestinal (GI) bleeding, nosocomial pneumonia (NP), mortality, and length of stay in the pediatric intensive care unit (PICU). We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies in the English language assessing the effects of proton pump inhibitors and histamine-2 receptor antagonists on patients in the PICU published before October 2018 from the PubMed, Embase, CINAHL, and Cochrane Central Register of Controlled Trials databases. A random-effects Mantel-Haenszel risk difference (MHRD) model was used to pool all the selected studies for meta-analysis. Primary outcomes were the incidences of GI bleeding and NP. Secondary outcomes included mortality and length of PICU stay. Seventeen studies (4 RCTs and 13 observational studies) with a total of 340 763 patients were included. The overall incidence of GI bleeding was 15.2%. There was no difference in the risk of GI bleeding based on stress ulcer prophylaxis status (MHRD, 5.0%; 95% CI, -1.0% to 11.0%; I2=62%). There was an increased risk of NP in patients who received stress ulcer prophylaxis compared with those who did not (MHRD, 5.3%; 95% CI, 3.5%-7.0%; I2=0%). An increased risk of mortality was seen in patients receiving stress ulcer prophylaxis (MHRD, 2.1%; 95% CI, 2.0%-2.2%; I2=0%), although this association was no longer found when 1 large study was removed in a sensitivity analysis. There was no statistically significant difference in length of PICU stay between the groups (standardized mean difference, 0.42days; 95% CI, -0.16 to 1.01days; I2=89.8%). Stress ulcer prophylaxis does not show a clear benefit in reducing GI bleeding or length of PICU stay. Observational studies suggest an increased risk of NP and mortality with stress ulcer prophylaxis, which remains to be validated in clinical trials.

Adequacy of stress ulcer prophylaxis prescription in the intensive care unit: an observational study.

Stress ulcer prophylaxis prescriptions might not be sufficiently challenged throughout a patient's stay in an intensive care unit (ICU) and might be erroneously maintained after ICU discharge. This study aimed to determine (1) stress ulcer prophylaxis adequacy in ICU and (2) the proportion of patients receiving inappropriate stress ulcer prophylaxis after ICU discharge. This was an observational, single centre study (University Hospital Lausanne, Switzerland). All patients without a previous indication for acid-suppressive therapy and admitted to our ICU for >24 hrs during a two-month period were included. The adequacy of stress ulcer prophylaxis prescriptions according to our guidelines was assessed. We then assessed stress ulcer prophylaxis prescriptions and their adequacy on ICU and hospital discharge, as well as the costs associated with inadequate prescription. Of the 372 patients admitted during the study period, 140 (855 patient-days) fulfilled the inclusion criteria. Of these, 130 (92.9%) received stress ulcer prophylaxis in the ICU (796 [93.1%] patient-days). Stress ulcer prophylaxis consisted of esomeprazole in 686 (86.2%) patient-days. Overall, stress ulcer prophylaxis was inadequate in 558 (65.3%) patient-days, mostly because it was prescribed while not indicated (543 patient-days [63.5%]). On ICU discharge, stress ulcer prophylaxis prescription was inadequately maintained in 55 patients (51.9% of survivors). Similarly, stress ulcer prophylaxis was inadequately maintained on hospital discharge in 30 (28% of survivors) patients. We estimated the in-hospital cost of inadequate stress ulcer prophylaxis prescription as approximately CHF 2870 per year. Outpatient therapy maintenance would be associated with additional costs ranging from CHF 33,912 to 92,692 (EUR 31,832 to 87,012) for each additional year they receive the therapy, depending on the medication used. The adequacy of stress ulcer prophylaxis in the ICU is low. In addition, the prescription is frequently continued after ICU and many patients are even discharged home with inadequate acid-suppressive therapy.   &nbsp.

Stress Ulcer Prophylaxis in Critically Ill Children: A Multicenter Observational Study.

To describe current stress ulcer prophylaxis practice in Canadian PICUs. Multicenter cohort study. We defined stress ulcer prophylaxis as the use of a proton-pump inhibitor, histamine-2 receptor antagonist, or sucralfate within the first 2 PICU days among children who had not been on these medications at home and had no evidence of gastrointestinal bleeding. Seven PICUs in Canada. Three hundred seventy-eight children requiring mechanical ventilation. None. Children were ventilated for a median (interquartile range) of 2 days (1-6 d) and stayed in the PICU for a median (interquartile range) of 4 days (2-10 d). The median (interquartile range) age was 1.3 years (0.3-6.7 yr). Seventy percent of all children received acid suppression during their PICU stay. One hundred sixty-seven (54%) of the 309 children eligible for stress ulcer prophylaxis received it. Histamine-2 receptor antagonists were the most frequently used class (66%), followed by proton-pump inhibitors (47%) and sucralfate (4%), and 20% received more than one class. Stress ulcer prophylaxis was continued on the PICU transfer orders for 34% of these children. Children who received prophylaxis were older and had a higher Pediatric Risk of Mortality III score, more often received nonsteroidal anti-inflammatory drugs and systemic corticosteroids and received less enteral nutrition. In multivariate analysis, age and invasive mechanical ventilation were independently associated with an increased likelihood of receiving stress ulcer prophylaxis and receiving feeds was independently associated with a decreased likelihood of receiving stress ulcer prophylaxis. Gastrointestinal bleeding was reported in 21 (6%) of 378 children; three (0.8%) were clinically important. Eighteen percent were treated for a new respiratory tract infection, and 1% developed Clostridium difficile-associated diarrhea. Stress ulcer prophylaxis is common in Canadian PICUs. Clinically important gastrointestinal bleeding and C. difficile-associated diarrhea are rare, and the utility of routine prophylaxis should be examined.

Stress ulcer prophylaxis with proton pump inhibitors or histamin-2 receptor antagonists in adult intensive care patients: a systematic review with meta-analysis and trial sequential analysis.

Most intensive care unit (ICU) patients receive stress ulcer prophylaxis. We present updated evidence on the effects of prophylactic proton pump inhibitors (PPIs) or histamine 2 receptor antagonists (H2RAs) versus placebo/no prophylaxis on patient-important outcomes in adult ICU patients. We conducted a systematic review with meta-analysis and trial sequential analysis (TSA) of randomised clinical trials assessing the effects of PPI/H2RA versus placebo/no prophylaxis on mortality, gastrointestinal (GI) bleeding, serious adverse events (SAEs), health-related quality of life (HRQoL), myocardial ischemia, pneumonia, and Clostridium (Cl.) difficile enteritis in ICU patients. We identified 42 trials randomising 6899 ICU patients; 3 had overall low risk of bias. We did not find an effect of stress ulcer prophylaxis on mortality [relative risk 1.03, 95% confidence interval (CI) 0.94-1.14; TSA-adjusted CI 0.94-1.14], but the occurrence of any GI bleeding was reduced as compared with placebo/no prophylaxis (0.60, 95% CI 0.47-0.77; TSA-adjusted CI 0.36-1.00). The conventional meta-analysis indicated that clinically important GI bleeding was reduced (RR 0.63, 95% CI 0.48-0.81), but the TSA-adjusted CI 0.35-1.13 indicated lack of firm evidence. The effects of stress ulcer prophylaxis on SAEs, HRQoL, pneumonia, myocardial ischemia and Cl. difficile enteritis are uncertain. In this updated systematic review, we were able to refute a relative change of 20% of mortality. The occurrence of GI bleeding was reduced, but we lack firm evidence for a reduction in clinically important GI bleeding. The effects on SAEs, HRQoL, pneumonia, myocardial ischemia and Cl. difficile enteritis remain inconclusive.

STRESS ULCER PROPHYLAXIS AS A RISK FACTOR FOR TRACHEAL COLONIZATION AND HOSPITAL-ACQUIRED PNEUMONIA IN INTENSIVE CARE PATIENTS: IMPACT ON LATENCY TIME FOR PNEUMONIA.

SUMMARYStress ulcer prophylaxis is associated with bacterial colonization of respiratory tract. The aims of our study were to determine risk factors for trachea colonization (TC), colonization of pharynx (CP) or stomach (CD) and hospital-acquired pneumonia (HAP), and divide the factors into those with high risk and low risk. The study population (ventilated intensive care unit (ICU) patients eligible to receive stress ulcer prophylaxis) was randomized to receive one of three different treatment protocols: ranitidine, sucralfate, and no stress ulcer prophylaxis (control group). Clinical data relative to pre-specified risk factors for TC or HAP were recorded, as follows: APACHE II score (second risk factor), duration of intubation or tracheotomy (third risk factor), duration of mechanical ventilation (fourth risk factor) and duration of hospitalization in the ICU (fifth risk factor). Gastric pH was recorded and microbiological data regarding stomach, pharynx and trachea were collected on the 1st, 2nd, 3rd and 5th day. Fifty-eight out of 81 patients developed HAP (including ventilator-associated pneumonia), which occurred later in patients with gastric content pH <4 or those that were tracheotomized. Stress ulcer prophylaxis was not associated with HAP; however, it was proved as a risk factor for TC. TC was detected in tracheotomized patients and was caused by gram-negative pathogens. CP was associated with TC, since the majority of patients had CP before TC. A combination of risk factors (APACHE II >18, age >65, mechanical ventilation and sedation) caused a higher incidence of HAP and lower incidence of TC. HAP was more frequent in patients staying in the ICU for >10 days and those with cardiovascular disease as the underlying disorder. Sedation and previous antibiotic therapy correlated with longer latent period (LAT), while higher values of gastric content pH were related to shorter LAT. The longest LAT was found in patients colonized with Acinetobacter spp. Risk factors that accelerated the occurrence of HAP were found to have caused previous colonization. A combination of risk factors increased the likelihood of TC and HAP, and shortened LAT between TC and HAP.

Timing of onset of gastrointestinal bleeding in the ICU: Protocol for a preplanned observational study.

Critically ill patients are at risk of gastrointestinal bleeding, but clinically important gastrointestinal bleeding is rare. The majority of intensive care unit (ICU) patients receive stress ulcer prophylaxis (SUP), despite uncertainty concerning the balance between benefit and harm. For approximately half of ICU patients with gastrointestinal bleeding, onset is early, ie within the first two days of the ICU stay. The aetiology of gastrointestinal bleeding and consequently the balance between benefit and harm of SUP may differ between patients with early vs late gastrointestinal bleeding. This is a protocol and statistical analysis plan for a preplanned exploratory substudy of the Stress Ulcer Prophylaxis in the Intensive Care Unit (SUP-ICU) randomized clinical trial, comparing intravenous pantoprazole (40mg once daily) with placebo in 3350 acutely ill adult ICU patients. We will describe baseline characteristics and assess the time to onset of the first clinically important episode of GI bleeding accounting for survival status and allocation to SUP or placebo. In addition, we will describe differences in therapeutic and diagnostic procedures used in patients with clinically important gastrointestinal bleeding according to early vs late bleeding and 90-day vital status. The study outlined in this protocol will provide detailed information on patient characteristics and the timing of onset of gastrointestinal bleeding in the patients enrolled in the SUP-ICU trial. This may provide additional knowledge and incentives for future studies on which patients benefit from SUP.

Evaluation of Adherence to American Society of Health-System Pharmacists Guidelines: Stress Ulcer Prophylaxis in Shiraz, Iran.

Overuse of stress ulcer prophylaxis has a considerable cost burden on patient and healthcare systems. This study aimed to determine the adherence level of stress ulcer prophylaxis use with American Society of Health-System Pharmacists guidelines in a teaching hospital in Shiraz, Iran. From March to September 2013, we enrolled all eligible patients admitted to the general medical wards of Shahid Faghihi Hospital, Shiraz, Iran. According to American Society of Health-System Pharmacists guidelines, patients who had at least one major or two minor risk factors for stress ulcers and received stress ulcer prophylaxis were labeled as adherent, others were considered nonadherent. During the study period, 441 patients enrolled, of which 257 (58.3%) were women. The mean ±SD age of patients was 54.7 ± 20 years. The mean ±SD length of hospital stay for patients was 11.3 ± 6 days. Overall, 354 patients (80.2%) received proton pump inhibitors as stress ulcer prophylaxis. There were 127 patients who properly received stress ulcer prophylaxis. Total adherence to American Society of Health-System Pharmacists guidelines in our hospital was 28.8%. We observed a high frequency of unnecessary use of stress ulcer prophylaxis in hospitalized, noncritically ill patients with inappropriate continuation after discharge.

We No Longer Need to Stress Ulcer Prophylaxis in the Critically Ill

Preventing stress gastropathy has been a mainstay in the management of critically ill patients for decades. A landmark trial in 1994 identified the most significant risk factors for stress gastropathy as mechanical ventilation for greater than 48 h and primary coagulopathy. Since this study's publication more than two decades ago, the incidence of clinically significant gastrointestinal bleeding secondary to stress gastropathy has significantly declined. In addition, the most widely used agents for prophylaxis have been associated with an increasing number of adverse effects, including myocardial infarction, Clostridium difficile infection, osteoporosis and ventilator associated pneumonia. As the incidence of significant bleeding decreases and the knowledge about prophylaxis-related adverse events increases, it is necessary to revisit current clinical practice. Major practice changes, including early aggressive fluid resuscitation and development of dynamic markers for volume status, have reduced the likelihood for prolonged hypoperfusion states. Additionally, the recognition of the important of enteral nutrition early in the ICU stay encourages mesenteric perfusion and reduces risk for development of ischemic damage. Contemporary studies have failed to replicate significant rates of gastrointestinal bleeding, likely in part due to these advances in care. Recent studies, including a pilot randomized trial, are questioning the necessity of pharmacologic prophylaxis in the modern era, with undetectable rates of gastrointestinal bleeding in enrolled patients. Patients with risk factors for stress gastropathy who demonstrate no evidence of splanchnic hypoperfusion may not benefit from receiving stress ulcer prophylaxis and tolerance of enteral nutrition may be used as a surrogate marker for adequate perfusion. Overall there is a lack of high quality data supporting stress ulcer prophylaxis in the modern era.

Risks and Benefits of Stress Ulcer Prophylaxis for Patients With Severe Sepsis.

The Surviving Sepsis Campaign Guidelines recommend stress ulcer prophylaxis for patients with severe sepsis who have bleeding risks. Although sepsis has been considered as a risk factor for gastrointestinal bleeding, the effect of stress ulcer prophylaxis has not been studied in patients with severe sepsis. Furthermore, stress ulcer prophylaxis may be associated with an increased risk of hospital-acquired pneumonia or Clostridium difficile infection. The aim of this study was to investigate the risks and benefits of stress ulcer prophylaxis for patients with severe sepsis. Retrospective cohort study. Five hundred twenty-six acute care hospitals in Japan. A total of 70,862 patients with severe sepsis. None. One-to-one propensity score matching created 15,651 pairs of patients who received stress ulcer prophylaxis within 2 days of admission and those who did not. Patient characteristics were well balanced between the two groups. No significant differences were seen between the stress ulcer prophylaxis group and the control group with regard to gastrointestinal bleeding requiring endoscopic hemostasis (0.6% vs 0.5%; p = 0.208), 30-day mortality (16.4% vs 16.9%; p = 0.249), and Clostridium difficile infection (1.4% vs 1.3%; p = 0.588). The stress ulcer prophylaxis group had a significantly higher proportion of hospital-acquired pneumonia (3.9% vs 3.3%; p = 0.012) compared with the control group. Since the rate of gastrointestinal bleeding requiring endoscopic hemostasis is not different comparing patients with and without stress ulcer prophylaxis, and the increase in hospital-acquired pneumonia is significant, routine stress ulcer prophylaxis for patients with severe sepsis may be unnecessary.

Use of acid suppression medications in postoperative cardiac surgical intensive care unit patients

Background Acid suppression medications are routinely used in general intensive care unit patients for prevention of stress-related gastric mucosal bleeding. Their use has been extrapolated to include elective postoperative cardiac surgical patients. The evidence for their use in this group of patients remains inconclusive (Shin and Abah, Interact Cardiovasc Thorac Surg, 2012; 14: 622-8). Aim To audit the use of acid suppression therapy in postoperative cardiac surgical patients as inpatients and after discharge, and ascertain whether these patients experienced postoperative gastrointestinal bleeding. Method A retrospective chart review was undertaken, focusing on cases of cardiac surgical intensive care patients to investigate the use of stress ulcer prophylaxis and the occurrence of post-surgical gastrointestinal bleeding. The continuation of therapy after discharge was also audited. Results The cases of 78 patients were included in the audit: all received stress ulcer prophylaxis, and no patients experienced gastrointestinal bleeding postoperatively. In all, 27% of these patients were dispensed acid suppression therapy without a valid indication at the time of discharge. Conclusions It cannot be conclusively determined if the absence of postoperative gastrointestinal bleeding was due to the administration of prophylaxis. An alternative explanation is that stress ulcers were not likely to occur in this cohort of patients. Despite not having any indication for continuation of acid suppression, 20 patients were discharged with these medications.

Administration of proton pump inhibitors in critically ill medical patients is associated with increased risk of developing Clostridium difficile–associated diarrhea

PurposeProton pump inhibitors (PPIs) effectively prevent gastrointestinal bleedings in critically ill patients at the intensive care unit (ICU). In non-ICU hospitalized patients, PPI administration increases the risk of infectious complications, especially Clostridium difficile–associated diarrhea (CDAD); but no such data are available for the ICU setting. Materials and methodsThis is a retrospective, observational, single-center analysis (1999-2010) including 3286 critically ill patients. ResultsA total of 91.3% of patients received stress ulcer prophylaxis by PPI (55.6%), histamine 2 receptor antagonists (5.8%), sucralfate (10.1%), or combinations (19.8%). Only 29 (0.9%) of 3286 patients developed gastrointestinal bleedings during the course of ICU treatment, independent from the type of prophylaxis. The PPIs were not an independent risk factor for nosocomial pneumonia. One hundred and ten (3.3%) patients developed CDAD during the course of ICU treatment, which was associated with prolonged ICU stay and increased ICU mortality (odds ratio, 1.59). Similar to fluoroquinolones and cephalosporins, PPI was identified as an independent risk factor (odds ratio, 3.11) for developing CDAD at the ICU by multivariate analysis. ConclusionsProton pump inhibitor therapy was an independent risk factor for CDAD in medical ICU patients. Instead of routine PPI use for bleeding prophylaxis, further trials should investigate risk-adjusted algorithms, balancing benefits, and threats of PPI medication.

Gastrointestinal Bleeding After Intracerebral Hemorrhage: A Retrospective Review of 808 Cases

BackgroundThis study examined the incidence and risk factors for gastrointestinal (GI) bleeding after spontaneous intracerebral hemorrhage (ICH). MethodsThe available medical records of patients with ICH admitted from June 2008 to December 2009 for any episode of GI bleeding, possible precipitating factors and administration of ulcer prophylaxis were reviewed. ResultsThe prevalence of GI bleeding was 26.7%, including 3 cases of severe GI bleeding (0.35%). Patients with GI bleeding had significantly longer hospital stay and higher in-hospital mortality compared with patients without GI bleeding. Multivariate logistic regression analyses showed that age, Glasgow Coma Scale scores, sepsis and ICH volume were independent predictors of GI bleeding. About 63.4% of patients with ICH received stress ulcer prophylaxis. ConclusionsGI bleeding occurred frequently after ICH, but severe events were rare. Age, Glasgow Coma Scale score, sepsis and ICH volume were independent predictors of GI bleeding occurring after ICH.

Evaluation of an alternative posaconazole prophylaxis regimen in haematological malignancy patients receiving concomitant stress ulcer prophylaxis

Posaconazole (PCZ) is approved for fungal prophylaxis in high-risk neutropenic patients. Unfortunately, PCZ oral absorption is affected by nutritional intake and drug interactions with proton pump inhibitors (PPIs) and possibly histamine-2 antagonists (H2As). Cancer patients frequently receive stress ulcer prophylaxis (SUP) with PPIs or H2As. Recommended PCZ steady-state concentrations (Css) are difficult to achieve using the traditional dosing regimen of 200mg thrice daily. Given the paucity of guidance on PCZ dosing in patients receiving SUP, this study evaluated attainment of targeted PCZ Css (0.5μg/mL and 0.7μg/mL) with two different PCZ dosing regimens when SUP was given. Twenty patients received the traditional dosing and 34 patients received 400mg twice daily. Median PCZ Css levels were 0.37μg/mL and 0.32μg/mL with the traditional and 400mg twice-daily regimens, respectively (P=0.809). When stratified by type of SUP, H2A patients had a median PCZ Css of 0.39μg/mL, whereas PPI patients had a median PCZ Css of 0.32μg/mL. Despite having more patients with PCZ Css >0.5μg/mL in the H2A group, a statistical significance was not found (P=0.368). Multiple logistic regression did show that increasing age [odds ratio (OR)=1.08, 95% confidence interval (CI) 1.03–1.19] and use of H2As over PPIs (OR=6.8, 95% CI 1.22–55.16] was associated with PCZ target attainment. These results suggest that PCZ target attainment is similar with either PCZ regimen but that there may be less of an interaction with H2As compared with PPIs.

Patterns of Use of Prophylaxis for Stress-Related Mucosal Disease in Patients Admitted to the Intensive Care Unit

Morbidity associated with stress ulcer-related bleeding, the cost of medications, and the possible complications associated with stress ulcer prophylaxis are important considerations when prescribing prophylaxis. We prospectively studied the prescription patterns for stress ulcer prophylaxis in patients admitted to our ICU. We prospectively recorded the indications for stress ulcer prophylaxis and prescription patterns for use based on the American Society of Healthcare Pharmacists criteria and other indications for 99 new intensive care unit (ICU) admissions to a tertiary referral center. In all 51 patients had no indication for stress ulcer prophylaxis, 32 had 1 indication, 14 had 2 indications, and 2 patients had 3 indications for receiving stress ulcer prophylaxis in the ICU. Eighty-two percent of patients without any indications received stress ulcer prophylaxis; 81% of patients with 1 indication, 79% of patients with 2 indication, and 50% of patients with 3 indications received stress ulcer prophylaxis. Overall, 53% of patients either received stress ulcer prophylaxis when none was indicated or did not receive stress ulcer prophylaxis when it was indicated. We also review the recent literature on stress-related mucosal disease and the use of prophylaxis for stress-related mucosal disease. Stress ulcer prophylaxis administration in this ICU is inconsistent and includes both underutilization and overutilization. Educating physicians and implementing hospital protocols could improve use patterns.

Stress ulcer prophylaxis in pediatric intensive care units

To assess use of stress ulcer prophylaxis in patients admitted to five pediatric intensive care units (PICUs) in Porto Alegre, Brazil. This was a multicenter, prospective, cross-sectional observational study. PICUs were visited on randomly defined days between April 2006 and February 2007, and the medical records of admitted patients were reviewed. Patients whose records had been previously assessed were excluded, as were those with upper gastrointestinal bleeding on admission. Data were collected on age, gender, admission diagnosis, severity of illness, administration of stress ulcer prophylaxis, rationale for prophylaxis, and first-line prophylactic agent of choice. Variables were described as absolute and relative frequencies, mean and standard deviation, or median and interquartile range as appropriate. Pearson's chi-square test for linear trend or Fisher's exact test were used to assess possible associations. The level of significance was set at 5% (p ≤ 0.05). 398 patients (57% male) were assessed [median age, 16 months (IQR 4-65); median length of PICU stay, 4 days (IQR 1-9)]. Respiratory illness was the main reason for admission (32.7%). Most patients received stress ulcer prophylaxis (77.5%; range, 66-91%). Mechanical ventilation (22.3%) was the most common rationale provided, followed by informal routine use of prophylaxis (21.4%). Only one of the participating PICUs had a specific care protocol for use of stress ulcer prophylaxis. Ranitidine was the most commonly used drug (84.5% of cases). Evidence of minor gastrointestinal bleeding was found in 3% of patients; none had clinically significant bleeds. Administration of stress ulcer prophylaxis is a common practice in the participating PICUs, with ranitidine the most commonly used drug. Among the various rationales provided, mechanical ventilation and informal routine use were the most prevalent.

Profilaxia para úlcera de estresse em pacientes internados em UTI pediátrica

OBJECTIVE: To assess use of stress ulcer prophylaxis in patients admitted to five pediatric intensive care units (PICUs) in Porto Alegre, Brazil. METHODS: This was a multicenter, prospective, cross-sectional observational study. PICUs were visited on randomly defined days between April 2006 and February 2007, and the medical records of admitted patients were reviewed. Patients whose records had been previously assessed were excluded, as were those with upper gastrointestinal bleeding on admission. Data were collected on age, gender, admission diagnosis, severity of illness, administration of stress ulcer prophylaxis, rationale for prophylaxis, and first-line prophylactic agent of choice. Variables were described as absolute and relative frequencies, mean and standard deviation, or median and interquartile range as appropriate. Pearson's chi-square test for linear trend or Fisher's exact test were used to assess possible associations. The level of significance was set at 5% (p < 0.05). RESULTS: 398 patients (57% male) were assessed [median age, 16 months (IQR 4-65); median length of PICU stay, 4 days (IQR 1-9)]. Respiratory illness was the main reason for admission (32.7%). Most patients received stress ulcer prophylaxis (77.5%; range, 66-91%). Mechanical ventilation (22.3%) was the most common rationale provided, followed by informal routine use of prophylaxis (21.4%). Only one of the participating PICUs had a specific care protocol for use of stress ulcer prophylaxis. Ranitidine was the most commonly used drug (84.5% of cases). Evidence of minor gastrointestinal bleeding was found in 3% of patients; none had clinically significant bleeds. CONCLUSIONS: Administration of stress ulcer prophylaxis is a common practice in the participating PICUs, with ranitidine the most commonly used drug. Among the various rationales provided, mechanical ventilation and informal routine use were the most prevalent.

Stress-related mucosal bleeding in critically ill oncology patients

To determine the incidence of stress-related mucosal bleeding (SRMB) in a critically ill oncology population receiving stress ulcer prophylaxis (SUP) with either a histamine-2 receptor antagonist (H2RA) or proton pump inhibitor (PPI). Single-center, prospective, observational study. Fifty-two bed medical-surgical intensive care unit of an academic oncology institution. A convenience sample of 100 medical and surgical critically ill oncology patients who received intensive care for more than 24 hours and at least one dose of a H2RA or PPI for prevention of SRMB. None. Patients were followed throughout their intensive care unit stay for the development of an overt and/or clinically significant gastrointestinal (GI) bleed. More patients received a PPI (n=81) in contrast to a H2RA (n=19) for SUP. Overall, 94 patients (94%) had at least one risk factor for a SRMB with four patients (4%) experiencing an event (overt bleed, n=3; clinically significant bleed, n=1). All cases of GI bleeding occurred in patients receiving a PPI. No ICU deaths were considered directly related to a GI bleed. The incidence of SRMB among high-risk critically ill oncology patients receiving SUP appears low; further, large-scale trials are needed to confirm this finding.

Frequency of Inappropriate Continuation of Acid Suppressive Therapy After Discharge in Patients Who Began Therapy in the Surgical Intensive Care Unit

To determine the frequency with which patients who begin to receive stress ulcer prophylaxis in the surgical intensive care unit (SICU) are discharged receiving inappropriate acid suppressive therapy (AST). Prospective, observational evaluation. Setting. Level 1 trauma center and academic tertiary care hospital. A total of 248 consecutive adult patients admitted to the SICU during a 6-month period who began to receive AST with a proton pump inhibitor or histamine(2)-receptor antagonist. In most patients (237 [95.6%] of 248), initiation of AST was associated with one or more risk factors for gastrointestinal bleeding. Continuation of AST during hospitalization outside the SICU occurred in 215 patients (86.7%). Sixty patients (24.2%) were discharged from the hospital receiving AST: 52 patients (21.0%) went to skilled nursing facilities or rehabilitation centers, and eight (3.2%) were discharged home. Compared with those whose AST was discontinued in the hospital, patients who continued to receive AST after hospital discharge required extended mechanical ventilation (p=0.001), had twice as many risk factors for gastrointestinal bleeding (p<0.001), were frequently discharged with anticoagulant therapy (p<0.001), exhibited longer hospital and SICU stays (p<0.001), and more frequently demonstrated Glasgow Coma Scale scores of 8 or lower and/or had head injury (p<0.001), hepatic failure (p=0.004), and major trauma (p=0.049). Evaluation of continuation of AST during hospitalization revealed that only 7.4% (16/215) of patients at SICU transfer and 5.0% (3/60) of patients at hospital discharge had a compelling risk factor to continue AST as demonstrated by a coagulopathy at discharge; no patients required mechanical ventilation at hospital discharge. Most patients inappropriately continued to receive stress ulcer prophylaxis during post-SICU hospitalization. Presence of risk factors for stress ulcer-related gastrointestinal bleeding at SICU admission appears to influence continuation of AST after discharge from the hospital. A low percentage (3.2%) of patients was discharged home receiving inappropriate AST, yet overall, few study patients demonstrated a compelling risk factor for continuation of AST.