Stress-related Gastrointestinal Bleeding Research Articles

Executive Summary-Society of Critical Care Medicine Guideline and American Society of Health-System Pharmacists for the Prevention of Stress-Related Gastrointestinal Bleeding in Critically Ill Adults.

Executive Summary-Society of Critical Care Medicine Guideline and American Society of Health-System Pharmacists for the Prevention of Stress-Related Gastrointestinal Bleeding in Critically Ill Adults.

Society of Critical Care Medicine and American Society of Health-System Pharmacists Guideline for the Prevention of Stress-Related Gastrointestinal Bleeding in Critically Ill Adults.

Critically ill adults can develop stress-related mucosal damage from gastrointestinal hypoperfusion and reperfusion injury, predisposing them to clinically important stress-related upper gastrointestinal bleeding (UGIB). The objective of this guideline was to develop evidence-based recommendations for the prevention of UGIB in adults in the ICU. A multiprofessional panel of 18 international experts from dietetics, critical care medicine, nursing, and pharmacy, and two methodologists developed evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guideline development including task force selection and voting. The panel members identified and formulated 13 Population, Intervention, Comparison, and Outcome questions. We conducted a systematic review for each question to identify the best available evidence, statistically analyzed the evidence, and then assessed the certainty of the evidence using the GRADE approach. We used the evidence-to-decision framework to formulate the recommendations. Good practice statements were included to provide additional guidance. The panel generated nine conditional recommendations and made four good practice statements. Factors that likely increase the risk for clinically important stress-related UGIB in critically ill adults include coagulopathy, shock, and chronic liver disease. There is no firm evidence for mechanical ventilation alone being a risk factor. Enteral nutrition probably reduces UGIB risk. All critically ill adults with factors that likely increase the risk for stress-related UGIB should receive either proton pump inhibitors or histamine-2 receptor antagonists, at low dosage regimens, to prevent UGIB. Prophylaxis should be discontinued when critical illness is no longer evident or the risk factor(s) is no longer present despite ongoing critical illness. Discontinuation of stress ulcer prophylaxis before transfer out of the ICU is necessary to prevent inappropriate prescribing. The guideline panel achieved consensus regarding the recommendations for the prevention of stress-related UGIB. These recommendations are intended for consideration along with the patient's existing clinical status.

Significant risk factors for intensive care unit-acquired weakness: A processing strategy based on repeated machine learning.

Intensive care unit-acquired weakness (ICU-AW) is a common complication that significantly impacts the patient's recovery process, even leading to adverse outcomes. Currently, there is a lack of effective preventive measures. To identify significant risk factors for ICU-AW through iterative machine learning techniques and offer recommendations for its prevention and treatment. Patients were categorized into ICU-AW and non-ICU-AW groups on the 14th day post-ICU admission. Relevant data from the initial 14 d of ICU stay, such as age, comorbidities, sedative dosage, vasopressor dosage, duration of mechanical ventilation, length of ICU stay, and rehabilitation therapy, were gathered. The relationships between these variables and ICU-AW were examined. Utilizing iterative machine learning techniques, a multilayer perceptron neural network model was developed, and its predictive performance for ICU-AW was assessed using the receiver operating characteristic curve. Within the ICU-AW group, age, duration of mechanical ventilation, lorazepam dosage, adrenaline dosage, and length of ICU stay were significantly higher than in the non-ICU-AW group. Additionally, sepsis, multiple organ dysfunction syndrome, hypoalbuminemia, acute heart failure, respiratory failure, acute kidney injury, anemia, stress-related gastrointestinal bleeding, shock, hypertension, coronary artery disease, malignant tumors, and rehabilitation therapy ratios were significantly higher in the ICU-AW group, demonstrating statistical significance. The most influential factors contributing to ICU-AW were identified as the length of ICU stay (100.0%) and the duration of mechanical ventilation (54.9%). The neural network model predicted ICU-AW with an area under the curve of 0.941, sensitivity of 92.2%, and specificity of 82.7%. The main factors influencing ICU-AW are the length of ICU stay and the duration of mechanical ventilation. A primary preventive strategy, when feasible, involves minimizing both ICU stay and mechanical ventilation duration.

Prediction of stress-related gastrointestinal bleeding in patients with aneurysmal subarachnoid hemorrhage using caudate Hounsfield unit value in ASPECT score.

Stress-related gastrointestinal bleeding (SRGB) is one of the major complications after aneurysmal subarachnoid hemorrhage (aSAH), and it can present challenges in patient care and treatment. The aim of this study was to explore the clinical significance of the caudate Hounsfield unit (HU) value in the Alberta Stroke Program Early CT (ASPECT) score for predicting SRGB in patients with aSAH. We retrospectively analyzed the data of 531 aSAH patients admitted to our institution between 2019 and 2022. Potential predictors of SRGB were identified using multivariate Cox regression analysis. We used a restricted cubic spline (RCS) to evaluate whether there is a nonlinear relationship between the right caudate HU value and SRGB. MaxStat analysis (titled as maximally selected rank statistics) was performed to identify the optimal cutoff point for the right caudate HU value. Another Kaplan-Meier method with the log-rank test was used to analyze the right caudate HU value in predicting the occurrence of SRGB. The incidence rate of SRGB was 17.9%. In the multivariate Cox regression analysis, the right caudate HU value was an independent predictor of SRGB [Hazard ratio (HR) = 0.913; 95% confidence interval (CI): 0.847-0.983, and p = 0.016]. The RCS indicated that the incidence of developing SRGB reduces with increasing right caudate HU values (nonlinear p = 0.78). The optimal cut-off value of the right caudate HU was 25.1. Among aSAH patients, lower right caudate HU values indicated a higher risk of developing SRGB. Our findings provide further evidence for the relationship between the gastrointestinal system and the brain.

A Nomogram for Individualized Prediction of Stress-Related Gastrointestinal Bleeding in Critically Ill Patients with Primary Intracerebral Hemorrhage.

PurposeTo establish and validate a nomogram model for predicting stress-related gastrointestinal bleeding in critically ill patients with primary intracerebral hemorrhage.Patients and MethodsFrom January 2018 to March 2021, we conducted a hospital-based study by screening eligible patients with acute intracerebral hemorrhage. Univariate and multivariate logistic regression analyses were performed to determine the predictors for stress-related gastrointestinal bleeding in patients with primary intracerebral hemorrhage. The nomogram was constructed on the basis of multivariate logistic model and was internally validated by bootstrap resampling. The discriminative performance of the nomogram was evaluated using the calibration and concordance index (C-index), which was equal to the area under the curve of receiver-operating characteristics. Hosmer-Lemeshow test was performed to check the model’s goodness of fit. A decision curve analysis was used to assess its clinical utility.ResultsA total of 410 patients were enrolled in this study. Stress-related gastrointestinal bleeding occurred in 115 patients (28.0%). Multivariate analysis demonstrated that gastric pH at admission [odds ratio (OR): 0.52, 95% confidence interval (CI): 0.41–0.66, P < 0.001], ICH volume (OR: 1.03, 95% CI: 1.02–1.05, P < 0.001) and sepsis (OR: 2.56, 95% CI: 1.54–4.25, P < 0.001) were independent predictors for stress-related gastrointestinal bleeding in critically ill patients with ICH. The nomogram including gastric pH at admission, ICH volume and sepsis presented good discrimination with C-index of 0.770 (95% CI: 0.716 to 0.822), which was confirmed to be 0.764 through bootstrapping validation. The calibration plot showed good agreement between the predicted and observed outcomes. The Hosmer–Lemeshow test showed a goodness-of-fit (Chi-Square = 8.085, DF = 8, P = 0.425). Decision curve analysis demonstrated that the nomogram was clinically beneficial.ConclusionThe proposed nomogram based on gastric pH at admission, ICH volume and sepsis can accurately predict the risk of stress-related gastrointestinal bleeding in critically ill patients with primary intracerebral hemorrhage.

Stress ulcer prophylaxis in intensive care unit patients receiving enteral nutrition: a systematic review and meta-analysis

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.

Stress Ulcer Prophylaxis in Neurocritical Care.

Stress ulcer prophylaxis (SUP) with acid-suppressive drug therapy is widely utilized in critically ill patients following neurologic injury for the prevention of clinically important stress-related gastrointestinal bleeding (CIB). Data supporting SUP, however, largely originates from studies conducted during an era where practices were vastly different than what is considered routine by today's standard. This is particularly true in neurocritical care patients. In fact, the routine provision of SUP has been challenged due to an increasing prevalence of adverse drug events with acid-suppressive therapy and the perception that CIB rates are sparse. This narrative review will discuss current controversies with SUP as they apply to neurocritical care patients. Specifically, the pathophysiology, prevalence, and risk factors for CIB along with the comparative efficacy, safety, and cost-effectiveness of acid-suppressive therapy will be described.

Efficacy of microsurgical treatment of medulla hemangioblastoma

Objective To explore the microsurgical outcome of medulla hemangioblastomas. Methods A total of 88 cases of medulla hemangioblastoma underwent microsurgical treatment assisted with intraoperative neurophysiological monitoring at Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University between June 2011 and June 2016, whose clinical data and surgical outcomes were retrospectively analyzed. Results Among the 88 patients of medulla hemangioblastoma, 38 cases were cyst and solid and the remaining ones were purely solid. Moreover, there were 70 cases with a single lesion and 18 cases with multiple lesions. The Von Hippel-Lindau syndrome was present in 18 (20.5%) patients. All dorsal medullary tumors underwent gross total resection (GTR). Three (3.4%) deaths occurred postoperatively due to pulmonary infection. Temporary pulmonary embolism occurred in one patient. Other complications were also documented including stress-related gastrointestinal bleeding in 3 cases, pneumonia in 24(27.3%) cases, hematoma in 5 cases, deep venous thrombosis (DVT) in 7 cases, cerebrospinal fluid (CSF) leakage in 4 cases and infection of central nervous system in 6 cases. Eighty-one patients were followed up for about 3-60 months. Dizziness, headache, nausea and vomiting were reported in 56 instances, all of which were improved to varying degrees within 6 months. Out of 17 cases with decreased muscle strength prior to operations, 11 recovered and the others remained the same. Among 15 cases who presented with the lower cranial nerve-related symptoms, 9 were improved but the other 6 were not. Tumor recurrence developed in 15(17.0%) patients postoperatively including 2 cases with local recurrence that occurred 4 years and 10 years post GTR, respectively, and underwent the second operation. There were 13 cases developing tumor recurrence in other regions and 10 out of them underwent the second operation. Three (3.4%) patients died during the follow-up. Conclusion Satisfactory clinical outcomes could be achieved through microsurgery assisted with intraoperative neurophysiological monitoring. Key words: Hemangioblastoma; Medulla oblongata; Microsurgery

Gastric Acid Suppressant Prophylaxis in Pediatric Intensive Care: Current Practice as Reflected in a Large Administrative Database.

Stress-related gastrointestinal bleeding may occur in PICU patients. Raising gastric pH with acid suppressant medications is the accepted treatment. We describe the use of histamine 2 receptor blockers and proton pump inhibitors and associated factors among a national sample of PICU patients. Retrospective cohort analysis using Pediatric Health Information System clinically detailed administrative database. Forty-two children's hospitals throughout the United States. All hospitalizations for all patients 20 years old or younger, admitted directly to a PICU, from January 1, 2007, through December 31, 2011. None. The exposure of interest was treatment with a histamine 2 receptor blocker, proton pump inhibitor, or both on the first day of PICU admission. Demographics, principal and additional diagnoses, and procedure codes were assessed. For each hospitalization, principal diagnosis, coagulation disorder, head trauma, spinal trauma, severe burns, sepsis, gastrointestinal hemorrhage, mechanical ventilation, blood product transfusion, and 10 complex chronic conditions were identified. The frequency of principal diagnoses was determined to identify the most prevalent PICU diseases. Acid suppressant use was categorized as high or low. Three hundred and thirty-six thousand ten inpatient hospitalizations were sampled. Histamine 2 receptor blocker or proton pump inhibitor was used in 60.0%, with histamine 2 receptor blocker alone in 70.4%, proton pump inhibitor alone in 17.8%, and both agents in 11.8%. Use increased over the sample years 2007 through 2011. Gastrointestinal bleeding occurred in 1.32% of hospitalizations with transfusion needed in 0.1%. Among most prevalent diagnoses, histamine 2 receptor blocker and proton pump inhibitor use ranged from 33% to 87%. Sepsis, coagulopathy, and mechanical ventilation identified higher use. Use of histamine 2 receptor blocker or proton pump inhibitor among hospitals varied considerably ranging from 28% to 87%. Histamine 2 receptor blocker and proton pump inhibitor are prescribed in most PICU patients, but significant variation exists across health conditions and hospitals. Institutional preferences likely influence variation. Gastrointestinal hemorrhage is infrequent in the current era. Study data limitations prevent examination of associations between medication use and patient outcomes.

Stressulkus-Prophylaxe bei septischen Patienten - Ein evidenzbasierter Überblick

In spite of decreasing incidence stress-related gastrointestinal bleeding is still an important problem in intensive care medicine. Especially patients with severe sepsis or septic shock are prone to develop lesions of the upper gastrointestinal tract with consecutive bleeding. In order to prevent gastrointestinal bleeding various pharmacological agents are used to either suppress gastric acid or neutralize its effect. The following article presents an update on important aspects of stress-related mucosal disease. It further reviews current literature to provide evidence-based recommendations for stress ulcer prophylaxis in septic patients.

Therapeutic aspects of fat embolism syndrome

Signs and symptoms of clinical fat embolism syndrome (FES) usually begin within 24-48 hours after trauma. The classic triad involves pulmonary changes, cerebral dysfunction, and petechial rash. Clinical diagnosis is key because laboratory and radiographic diagnosis is not specific and can be inconsistent. The duration of FES is difficult to predict because it is often subclinical or may be overshadowed by other illnesses or injuries. Medical care is prophylactic or supportive, including early fixation and general ICU management to ensure adequate oxygenation and ventilation, hemodynamic stability, prophylaxis of deep venous thrombosis, stress-related gastrointestinal bleeding, and nutrition. Studies support early fracture fixation as a method to reduce recurrent fat embolism and FES. The main therapeutic interventions once FES has been clinically diagnosed are directed towards support of pulmonary and neurological manifestations and management of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS).

Clinically significant gastrointestinal bleeding in critically ill patients in an era of prophylaxis.

Clinical studies examining stress-related gastrointestinal bleeding in critically ill patients vary in their clinical definitions and assessment of clinical significance. Although there is evidence that routine prophylaxis decreases stress-related gastrointestinal bleeding, recent studies indicate a decreasing incidence, independent of the use of prophylactic medications. The purpose of this study was to determine the incidence of and risk factors for clinically significant, endoscopically proven gastrointestinal bleeding in critically ill patients. A database (prospectively collected data) of 8338 patients admitted to the surgical and medical intensive care units at major tertiary care center from July 1988 to April 1995 was examined. All patients with significant upper gastrointestinal bleeding as defined by a drop in hemoglobin of >20 g/L and endoscopic evidence of an upper GI tract source were identified. Risk factors for GI bleeding from stress ulceration were compared in bleeding and nonbleeding patients. A case-control study analyzing risk factors for bleeding in the abdominal aortic aneurysm subgroup was performed. After exclusion criteria, 12/7231 (0.17%) patients had clinically significant, endoscopically proven bleeding. Significant risk factors included age, septic shock, abdominal aortic aneurysm repair, and nutritional support. Intensive care unit stay was prolonged in patients with stress-related bleeding. There was no difference in incidence of hypotension, clamp time, APACHE score, or operating room time in patients with abdominal aortic aneurysm repair as compared with controls. In an intensive care unit where stress prophylaxis is widely used, clinically important gastrointestinal bleeding is uncommon. Further study is needed to define the optimal prophylaxis regimen and the role for its selective use in high-risk patients.

Clinically significant gastrointestinal bleeding in critically ill patients in an era of prophylaxis

OBJECTIVE: Clinical studies examining stress-related gastrointestinal bleeding in critically ill patients vary in their clinical definitions and assessment of clinical significance. Although there is evidence that routine prophylaxis decreases stress-related gastrointestinal bleeding, recent studies indicate a decreasing incidence, independent of the use of prophylactic medications. The purpose of this study was to determine the incidence of and risk factors for clinically significant, endoscopically proven gastrointestinal bleeding in critically ill patients. METHODS: A database (prospectively collected data) of 8338 patients admitted to the surgical and medical intensive care units at major tertiary care center from July 1988 to April 1995 was examined. All patients with significant upper gastrointestinal bleeding as defined by a drop in hemoglobin of >20 g/L and endoscopic evidence of an upper GI tract source were identified. Risk factors for GI bleeding from stress ulceration were compared in bleeding and nonbleeding patients. A case-control study analyzing risk factors for bleeding in the abdominal aortic aneurysm subgroup was performed. RESULTS: After exclusion criteria, 12/7231 (0.17%) patients had clinically significant, endoscopically proven bleeding. Significant risk factors included age, septic shock, abdominal aortic aneurysm repair, and nutritional support. Intensive care unit stay was prolonged in patients with stress-related bleeding. There was no difference in incidence of hypotension, clamp time, APACHE score, or operating room time in patients with abdominal aortic aneurysm repair as compared with controls. CONCLUSIONS: In an intensive care unit where stress prophylaxis is widely used, clinically important gastrointestinal bleeding is uncommon. Further study is needed to define the optimal prophylaxis regimen and the role for its selective use in high-risk patients.

ACUTE GASTROINTESTINAL BLEEDING IN THE INTENSIVE CARE UNIT: The Intensivist's Perspective

Gastrointestinal (GI) hemorrhage is a common and potentially lethal medical emergency that is a common cause for intensive care unit admission. The intensivist plays an important role as a member of the medical team managing the patient with GI bleeding who is at high risk because of severe bleeding, comorbidity, or the presence of endoscopic stigmata of recent hemorrhage. This article presents the intensivist's approach to GI hemorrhage in initial patient assessment, triage, resuscitation, specialist consultation, diagnostic evaluation, and medical therapy. This article focuses on types of GI bleeding of particular concern to the intensivist, including esophageal variceal bleeding, stress-related GI bleeding, and GI bleeding associated with myocardial infarcation.

Prophylaxis for stress-related gastrointestinal hemorrhage

The incidence of clinically important stress-related gastrointestinal hemorrhage (SRGIH) has decreased without the use of prophylaxis. This decline is probably attributable to improved care in the modern intensive care unit: aggressive correction of hypovolemia, adequate respiratory support, maintenance of tissue perfusion, and improved nutritional support. The majority of patients admitted to intensive care units are not at risk of developing clinically important SRGIH. Patients who are at high risk for SRGIH, and who may, therefore, benefit from prophylaxis, are those with at least one of the factors listed in Table 1. Antacids, histamine type 2-receptor antago-nists (H2 RA), proton pump inhibitors, and sucralfate all provide comparable protection from SRGIH. The choice of pharmacologic agent for prophylaxis therefore depends on other considerations, such as cost, side effects, and ease of administration. In this regard, it is still unclear whether these prophylactic medications increase the inci-dence of nosocomial pneumonia when administered to intensive care unit patients. Antacids may pose the greatest risk for developing pneumonia, followed by H2RA, and sucralfate. More research is necessary to resolve this important issue. Pharmacologic prophylaxis for SRGIH is cost effective only in high- risk populations. Based on existing literature, the cost of using of routine prophylaxis is prohibitive for at least two-thirds of patients admitted to intensive care units who are at low risk of SRGIH. When prophylaxis is administered to high-risk patients, the cost-per-averted-bleeding episode for sucralfate is lower than for other medications.

Prophylaxis for stress-related gastrointestinal hemorrhage: a cost effectiveness analysis.

To assess the cost-effectiveness of prophylaxis for stress-related gastrointestinal hemorrhage in patients admitted to the intensive care unit. Decision model of the cost and efficacy of sucralfate and cimetidine, two commonly used drugs for prophylaxis of stress-related hemorrhage. Outcome estimates were based on data from published studies. Cost data were based on cost of medications and costs of treatment protocols at our institutions. The marginal cost-effectiveness of prophylaxis, as compare with no prophylaxis, was calculated separately for sucralfate and cimetidine and expressed as cost per bleeding episode averted. An incremental cost-effectiveness analysis was subsequently employed to compare the two agents. Sensitivity analyses of the effects of the major clinical outcomes on the cost per bleeding episode averted were performed. At the base-case assumptions of 6% risk of developing stress-related hemorrhage and 50% risk-reduction due to prophylaxis, the cost of sucralfate was $1,144 per bleeding episode averted. The cost per bleeding episode averted was highly dependent on the risk of hemorrhage and, to a lesser degree, on the efficacy of sucralfate prophylaxis, ranging from a cost per bleeding episode averted of $103,725 for low-risk patients to cost savings for very high-risk patients. The cost per bleeding episode averted increased significantly if the risk of nosocomial pneumonia was included in the analysis. The effect of pneumonia was greater for populations at low risk of hemorrhage. Assuming equal efficacy, the cost per bleeding episode averted of cimetidine was 6.5-fold greater than the cost per bleeding episode averted of sucralfate. The cost of prophylaxis in patients at low risk of stress-related hemorrhage is substantial, and may be prohibitive. Further research is needed to identify patient populations that are at high risk of developing stress-related hemorrhage, and to determine whether prophylaxis increases the risk of nosocomial pneumonia.

Stress ulcer prophylaxis.

Preview Which critically ill patients are at increased risk for gastrointestinal hemorrhage from stress ulcers? Do prophylactic agents effectively reduce the morbidity and mortality associated with stress-related hemorrhage? The author, former director of a medical intensive care unit, reviews recent literature on stress ulcer prophylaxis and outlines the risks and benefits of providing preventive therapy.

Prophylaxis for Stress-related Gastric Hemorrhage in the Medical Intensive Care Unit

To determine the efficacy and safety of cimetidine and sucralfate prophylaxis for stress-related gastrointestinal hemorrhage in patients admitted to a medical intensive care unit. Medical intensive care unit of a nonprofit, university-affiliated teaching hospital. 300 patients admitted to the medical intensive care unit during a 10-month period. Randomized, controlled, single-blind clinical trial. Patients were assigned to receive no prophylaxis (control), 1 g sucralfate given orally every 6 hours, or continuous intravenous cimetidine titrated to maintain gastric pH at 4.0, intervention was maintained until the occurrence of clinically severe hemorrhage, onset of drug-related complications, death, or discharge from the medical intensive care unit. The primary outcome measure was the incidence of clinically severe hemorrhage from endoscopically verified stress-related gastritis. Other outcome measures were transfusion requirements, duration of medical intensive care unit stay, incidence of nosocomial pneumonia, adverse drug reactions, and death. 100 patients were randomly assigned to each treatment. The three groups were similar with regard to demographic characteristics, intensive care unit admission diagnoses, and APACHE II scores. Stress-related hemorrhage was seen in 6% of control participants and in 5% of those receiving sucralfate or cimetidine (relative risk compared with control, 0.83 for each group; 95% CI, 0.26 to 2.64; P = 0.75). No statistically significant differences were found for transfusion requirements, duration of medical intensive care unit stay, and mortality rates among the three groups. Nosocomial pneumonia was diagnosed in 6%, 12%, and 13% of controls, sucralfate recipients, and cimetidine recipients, respectively (sucralfate: relative risk, 2.0 [CI, 0.79 to 5.01], P = 0.14; cimetidine: relative risk, 2.2 [CI, 0.88 to 5.33], P = 0.09). Prophylaxis caused no definite adverse drug reactions. The observed effects of cimetidine and sucralfate on the incidence and severity of hemorrhage from stress-related gastritis were not significant when compared with no treatment. Routine prophylaxis with these agents for patients entering the medical intensive care unit does not seem warranted.

Stress Ulcers: Current Understanding of Pathogenesis and Prophylaxis

Stress-related gastrointestinal bleeding is known to occur in approximately 25 percent of untreated seriously ill patients, but with appropriate prophylaxis is largely preventable. Since the treatment of stress bleeding is generally unsatisfactory and has a high mortality, routine prophylaxis should be instituted for susceptible patients. Multiple mechanisms contribute to stress ulcer formation, the most important of which appear to be mucosal ischemia and the inability to control back-diffused hydrogen. Antacids and histamine2-blocking agents are presently the cornerstone of effective prophylaxis, but because they have been implicated as contributors to nosocomial pneumonias due to bacterial overgrowth in the stomach, investigation is ongoing into such alternative prophylactic agents as sucralfate and prostaglandins that do not alter the normal gastric acidity. This article presents a review of the literature on the development and prevention of stress ulcer disease.

Considerations for selection of parenteral histamine (H 2)-receptor antagonists

Parenteral histamine (H 2)-receptor antagonists are safe and effective therapy for the prophylaxis of stress-related erosive syndrome. Of the three agents available, parenteral cimetidine is the most widely studied; parenteral formulations of ranitidine and famotidine have not been investigated as extensively. Parenteral cimetidine appears to be effective in reducing incidence and complications associated with gastrointestinal hemorrhage caused by stress-related erosive syndrome, although its effects on bleeding that has already begun are not clear. Antacids are also effective in decreasing the incidence of stress-related gastrointestinal hemorrhage, but they are inconvenient and expensive to administer. Primed continuous infusions of cimetidine may be the most useful regimen for prophylaxis of stress-related erosive syndrome in critically ill patients; the evidence available on the efficacy of continuous infusions of ranitidine is inconsistent, and very few data are available on the value of famotidine. Direct comparative clinical trials are needed to assess definitively the efficacy of primed continuous infusions of cimetidine or other H 2-receptor antagonists versus that of antacid therapy.