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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: 0] [Impact Index Per Article: 0] [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.
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Jean-Baptiste S, Messika J, Hajage D, Gaudry S, Barbieri J, Duboc H, Dreyfuss D, Coffin B, Ricard JD. Clinical impact of upper gastrointestinal endoscopy in critically ill patients with suspected bleeding. Ann Intensive Care 2018; 8:75. [PMID: 29974284 PMCID: PMC6031555 DOI: 10.1186/s13613-018-0423-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 06/28/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND AIMS Upper gastrointestinal endoscopies' (UGE) profitability is undisputable in patients admitted for an overt upper digestive tract bleeding. In critically ill subjects admitted for other causes, its performances have scarcely been investigated despite its broad use. We sought to question the performance of bedside UGE in intensive care unit (ICU) patients, admitted for another reason than overt bleeding. METHODS This was a six-year (January 2007-December 2012) retrospective observational study of all UGE performed in a medico-surgical ICU. Exclusion of those performed: in patients admitted for a patent upper digestive bleeding; for a second-look gastroscopy of a known lesion; as a planned interventional procedure. Main demographic and clinical data were recorded; UGE indication and profitability were rated according to its findings and therapeutic impact. Operative values of the indications of UGE were calculated. This study received approval from the Ethics Committee of the French Society of Intensive Care (n° 12-363). RESULTS Eighty-four patients (74% male, mean age 61 ± 14 years) underwent a diagnostic UGE, all for a suspected upper digestive tract bleeding. The main symptoms justifying the procedure were anemia (52%), digestive bleeding (27%), vomiting (15%), hemodynamic instability (3%) and hyperuremia (3%). The profitability of UGE was rated as major (n = 5; 5.8%); minor (n = 34; 40.5%); or null (n = 45; 53.6%). CONCLUSIONS When ICU admission is not warranted by a digestive bleeding, UGE has limited diagnostic and therapeutic interest, despite being often performed.
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Affiliation(s)
- Sylvain Jean-Baptiste
- Medico-Surgical Intensive Care Unit, AP-HP, Hôpital Louis Mourier, 178 rue des Renouillers, 92700 Colombes, France
| | - Jonathan Messika
- Medico-Surgical Intensive Care Unit, AP-HP, Hôpital Louis Mourier, 178 rue des Renouillers, 92700 Colombes, France
- IAME, UMR 1137, INSERM, 75018 Paris, France
- IAME, UMR 1137, Univ Paris Diderot, Sorbonne Paris Cité, 75018 Paris, France
| | - David Hajage
- Département de Biostatistiques, Santé Publique et Information Médicale, AP-HP, Hôpital Pitié-Salpêtrière, 75013 Paris, France
- Univ Pierre et Marie Curie, Sorbonne Universités, 75013 Paris, France
- ECEVE, U1123, CIC-EC 1425, INSERM, 75010 Paris, France
- ECEVE, UMRS 1123, Univ Paris Diderot, Sorbonne Paris Cité, 75010 Paris, France
| | - Stéphane Gaudry
- Medico-Surgical Intensive Care Unit, AP-HP, Hôpital Louis Mourier, 178 rue des Renouillers, 92700 Colombes, France
- ECEVE, U1123, CIC-EC 1425, INSERM, 75010 Paris, France
- ECEVE, UMRS 1123, Univ Paris Diderot, Sorbonne Paris Cité, 75010 Paris, France
| | - Julie Barbieri
- Gastroenterology Unit, AP-HP, Hôpital Louis Mourier, 178 rue des Renouillers, 92700 Colombes, France
| | - Henri Duboc
- Univ Paris Diderot, Sorbonne Paris Cité, 75018 Paris, France
| | - Didier Dreyfuss
- Medico-Surgical Intensive Care Unit, AP-HP, Hôpital Louis Mourier, 178 rue des Renouillers, 92700 Colombes, France
- IAME, UMR 1137, INSERM, 75018 Paris, France
- IAME, UMR 1137, Univ Paris Diderot, Sorbonne Paris Cité, 75018 Paris, France
| | - Benoit Coffin
- Gastroenterology Unit, AP-HP, Hôpital Louis Mourier, 178 rue des Renouillers, 92700 Colombes, France
- Univ Paris Diderot, Sorbonne Paris Cité, 75018 Paris, France
| | - Jean-Damien Ricard
- Medico-Surgical Intensive Care Unit, AP-HP, Hôpital Louis Mourier, 178 rue des Renouillers, 92700 Colombes, France
- IAME, UMR 1137, INSERM, 75018 Paris, France
- IAME, UMR 1137, Univ Paris Diderot, Sorbonne Paris Cité, 75018 Paris, France
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Barbateskovic M, Marker S, Jakobsen JC, Krag M, Granholm A, Anthon CT, Perner A, Wetterslev J, Møller MH. Stress ulcer prophylaxis in adult intensive care unit patients - a protocol for a systematic review. Acta Anaesthesiol Scand 2018; 62:744-755. [PMID: 29577238 DOI: 10.1111/aas.13109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 02/25/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND In the intensive care unit (ICU), stress ulcer prophylaxis with proton pump inhibitors or histamine-2-receptor antagonists is standard of care although gastrointestinal bleeding remains uncommon. It remains unknown whether its use is associated with benefits or harms and the quality of evidence supporting the use of stress ulcer prophylaxis has been questioned. Accordingly, the objective of this systematic review was to critically assess the evidence from randomized clinical trials on the benefits and harms of stress ulcer prophylaxis vs. placebo or no prophylaxis in adult ICU patients. METHODS We will systematically search for randomized clinical trials in major international databases. Two authors will independently screen and select trials for inclusion, extract data and assess the methodological quality using the Cochrane risk of bias tool. Any disagreement will be resolved by consensus. We will perform conventional meta-analyses using Review Manager, and STATA 15, and we will assess the risk of random errors using Trial Sequential Analysis. Also, we will assess and report the overall quality of evidence for all outcomes according to GRADE. DISCUSSION The evidence on the benefits and harms of stress ulcer prophylaxis in adult ICU patients is unclear and an updated systematic review is warranted as new trials have been published. To control risks of systematic and random errors, we will use Cochrane and GRADE methodology and Trial Sequential Analysis. Our ambition with this systematic review is to provide updated, reliable and precise data to better inform decision makers on the use of stress ulcer prophylaxis in adult ICU patients.
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Affiliation(s)
- M. Barbateskovic
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen Denmark
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - S. Marker
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - J. C. Jakobsen
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen Denmark
- Department of Cardiology; Holbaek Hospital; Holbaek Denmark
| | - M. Krag
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - A. Granholm
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - C. T. Anthon
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - A. Perner
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - J. Wetterslev
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen Denmark
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - M. H. Møller
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
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Affiliation(s)
- Deborah Cook
- From the Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- From the Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
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Sun J, Sun H, Cui M, Sun Z, Li W, Wei J, Zhou S. The use of anti-ulcer agents and the risk of chronic kidney disease: a meta-analysis. Int Urol Nephrol 2018; 50:1835-1843. [DOI: 10.1007/s11255-018-1908-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 06/06/2018] [Indexed: 12/22/2022]
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Abstract
PURPOSE OF REVIEW To summarize and contextualize recent evidence on preventing ventilator-associated pneumonia (VAP). RECENT FINDINGS Many centers continue to report dramatic decreases in VAP rates after implementing ventilator bundles. Interpreting these reports is complicated, however, by the subjectivity and lack of specificity of VAP definitions. More objective data suggest VAP rates may not have meaningfully changed over the past decade. If so, this compels us to re-examine and revise the prevention bundles we have been using to prevent VAP. New analyses suggest that most hospitals' ventilator bundles include a mix of helpful and potentially harmful elements. Spontaneous awakening trials, spontaneous breathing trials, head-of-bed elevation, and thromboprophylaxis appear beneficial. Oral chlorhexidine and stress ulcer prophylaxis may be harmful. Subglottic secretion drainage, probiotics, and novel endotracheal cuff designs do not clearly improve objective outcomes. Selective digestive decontamination by contrast appears to lower VAP and mortality rates. Effective implementation is as important as choosing the right bundle components. Best practices include engaging and educating staff, creating structures that facilitate bundle adherence, and providing regular feedback on process measure performance and outcome rates. SUMMARY VAP rates may still be elevated despite multiple reports to the contrary. Recent evidence suggests new ways to optimize the selection of ventilator bundle components and their implementation.
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Toews I, George AT, Peter JV, Kirubakaran R, Fontes LES, Ezekiel JPB, Meerpohl JJ. Interventions for preventing upper gastrointestinal bleeding in people admitted to intensive care units. Cochrane Database Syst Rev 2018; 6:CD008687. [PMID: 29862492 PMCID: PMC6513395 DOI: 10.1002/14651858.cd008687.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Upper gastrointestinal (GI) bleeding due to stress ulcers contributes to increased morbidity and mortality in people admitted to intensive care units (ICUs). Stress ulceration refers to GI mucosal injury related to the stress of being critically ill. ICU patients with major bleeding as a result of stress ulceration might have mortality rates approaching 48.5% to 65%. However, the incidence of stress-induced GI bleeding in ICUs has decreased, and not all critically ill patients need prophylaxis. Stress ulcer prophylaxis can result in adverse events such as ventilator-associated pneumonia; therefore, it is necessary to evaluate strategies that safely decrease the incidence of GI bleeding. OBJECTIVES To assess the effect and risk-benefit profile of interventions for preventing upper GI bleeding in people admitted to ICUs. SEARCH METHODS We searched the following databases up to 23 August 2017, using relevant search terms: MEDLINE; Embase; the Cochrane Central Register of Controlled Trials; Latin American Caribbean Health Sciences Literature; and the Cochrane Upper Gastrointestinal and Pancreatic Disease Group Specialised Register, as published in the Cochrane Library (2017, Issue 8). We searched the reference lists of all included studies and those from relevant systematic reviews and meta-analyses to identify additional studies. We also searched the World Health Organization International Clinical Trials Registry Platform search portal and contacted individual researchers working in this field, as well as organisations and pharmaceutical companies, to identify unpublished and ongoing studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs with participants of any age and gender admitted to ICUs for longer than 48 hours. We excluded studies in which participants were admitted to ICUs primarily for the management of GI bleeding and studies that compared different doses, routes, and regimens of one drug in the same class because we were not interested in intraclass effects of drugs. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as recommended by Cochrane. MAIN RESULTS We identified 2292 unique records.We included 129 records reporting on 121 studies, including 12 ongoing studies and two studies awaiting classification.We judged the overall risk of bias of two studies as low. Selection bias was the most relevant risk of bias domain across the included studies, with 78 studies not clearly reporting the method used for random sequence generation. Reporting bias was the domain with least risk of bias, with 12 studies not reporting all outcomes that researchers intended to investigate.Any intervention versus placebo or no prophylaxisIn comparison with placebo, any intervention seems to have a beneficial effect on the occurrence of upper GI bleeding (risk ratio (RR) 0.47, 95% confidence interval (CI) 0.39 to 0.57; moderate certainty of evidence). The use of any intervention reduced the risk of upper GI bleeding by 10% (95% CI -12.0% to -7%). The effect estimate of any intervention versus placebo or no prophylaxis with respect to the occurrence of nosocomial pneumonia, all-cause mortality in the ICU, duration of ICU stay, duration of intubation (all with low certainty of evidence), the number of participants requiring blood transfusions (moderate certainty of evidence), and the units of blood transfused was consistent with benefits and harms. None of the included studies explicitly reported on serious adverse events.Individual interventions versus placebo or no prophylaxisIn comparison with placebo or no prophylaxis, antacids, H2 receptor antagonists, and sucralfate were effective in preventing upper GI bleeding in ICU patients. Researchers found that with H2 receptor antagonists compared with placebo or no prophylaxis, 11% less developed upper GI bleeding (95% CI -0.16 to -0.06; RR 0.50, 95% CI 0.36 to 0.70; 24 studies; 2149 participants; moderate certainty of evidence). Of ICU patients taking antacids versus placebo or no prophylaxis, 9% less developed upper GI bleeding (95% CI -0.17 to -0.00; RR 0.49, 95% CI 0.25 to 0.99; eight studies; 774 participants; low certainty of evidence). Among ICU patients taking sucralfate versus placebo or no prophylaxis, 5% less had upper GI bleeding (95% CI -0.10 to -0.01; RR 0.53, 95% CI 0.32 to 0.88; seven studies; 598 participants; moderate certainty of evidence). The remaining interventions including proton pump inhibitors did not show a significant effect in preventing upper GI bleeding in ICU patients when compared with placebo or no prophylaxis.Regarding the occurrence of nosocomial pneumonia, the effects of H2 receptor antagonists (RR 1.12, 95% CI 0.85 to 1.48; eight studies; 945 participants; low certainty of evidence) and of sucralfate (RR 1.33, 95% CI 0.86 to 2.04; four studies; 450 participants; low certainty of evidence) were consistent with benefits and harms when compared with placebo or no prophylaxis. None of the studies comparing antacids versus placebo or no prophylaxis provided data regarding nosocomial pneumonia.H2 receptor antagonists versus proton pump inhibitorsH2 receptor antagonists and proton pump inhibitors are most commonly used in practice to prevent upper GI bleeding in ICU patients. Proton pump inhibitors significantly more often prevented upper GI bleeding in ICU patients compared with H2 receptor antagonists (RR 2.90, 95% CI 1.83 to 4.58; 18 studies; 1636 participants; low certainty of evidence). When taking H2 receptor antagonists, 4.8% more patients might experience upper GI bleeding (95% CI 2.1% to 9%). Nosocomial pneumonia occurred in similar proportions of participants taking H2 receptor antagonists and participants taking proton pump inhibitors (RR 1.02, 95% CI 0.77 to 1.35; 10 studies; 1256 participants; low certainty of evidence). AUTHORS' CONCLUSIONS This review shows that antacids, sucralfate, and H2 receptor antagonists might be more effective in preventing upper GI bleeding in ICU patients compared with placebo or no prophylaxis. The effect estimates of any treatment versus no prophylaxis on nosocomial pneumonia were consistent with benefits and harms. Evidence of low certainty suggests that proton pump inhibitors might be more effective than H2 receptor antagonists. Therefore, patient-relevant benefits and especially harms of H2 receptor antagonists compared with proton pump inhibitors need to be assessed by larger, high-quality RCTs to confirm the results of previously conducted, smaller, and older studies.
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Affiliation(s)
- Ingrid Toews
- Medical Center, Faculty of Medicine, University of FreiburgEvidence in Medicine / Cochrane GermanyBreisacher Straße 153FreiburgBaden‐WürttembergGermany79110
| | - Aneesh Thomas George
- Christian Medical CollegeCochrane South Asia, Prof. BV Moses Centre for Evidence‐Informed Healthcare and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
| | - John V Peter
- Christian Medical College & HospitalMedical Intensive Care UnitIda Scudder RoadVelloreTamil NaduIndia632004
| | - Richard Kirubakaran
- Christian Medical CollegeCochrane South Asia, Prof. BV Moses Centre for Evidence‐Informed Healthcare and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
| | - Luís Eduardo S Fontes
- Petrópolis Medical SchoolDepartment of Evidence‐Based Medicine, Intensive Care, GastroenterologyAv Barao do Rio Branco, 1003PetrópolisRJBrazil25680‐120
| | - Jabez Paul Barnabas Ezekiel
- Christian Medical CollegeCochrane South Asia, Prof. BV Moses Centre for Evidence‐Informed Healthcare and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
| | - Joerg J Meerpohl
- Medical Center, Faculty of Medicine, University of FreiburgEvidence in Medicine / Cochrane GermanyBreisacher Straße 153FreiburgBaden‐WürttembergGermany79110
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Nourian A, Mohammadi M, Beigmohammadi MT, Taher M, Dadvar Z, Malekolkottab M, Ramezani M, Khalili H. Comparing efficacy of enteral nutrition plus ranitidine and enteral nutrition alone as stress ulcer prophylaxis. J Comp Eff Res 2018; 7:493-501. [DOI: 10.2217/cer-2017-0098] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Adequacy of enteral nutrition (EN) alone as stress ulcer prophylaxis (SUP) is controversial. The aim of this study was to compare efficacy of EN alone and ranitidine plus EN as SUP. Method: Critically ill adults with indications to receive SUP were randomized to ranitidine 50 mg IV every 8 h plus EN (SUP) or EN alone (non-SUP) group for 7 days. Besides, endoscopy was performed at the time of recruitment and on day 7. Results: During the study period, only one patient in each group of SUP and non-SUP experienced gastrointestinal bleeding. At the time of recruitment, gastric erosion and erythema were the most endoscopic findings in the SUP and non-SUP groups. These findings did not significantly change at the end of the study (p = 0.21). Conclusion: EN was at least effective as ranitidine plus EN as SUP.
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Affiliation(s)
- Anahid Nourian
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Mohammadi
- Department of Intensive Care Unit, Imam Khomeini Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad-Taghi Beigmohammadi
- Department of Intensive Care Unit, Imam Khomeini Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Taher
- Department of Internal Medicine, Imam Khomeini Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Zohreh Dadvar
- Department of Internal Medicine, Imam Khomeini Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoume Malekolkottab
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Ramezani
- Department of Intensive Care Unit, Imam Khomeini Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Khalili
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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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: 6.8] [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.
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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.
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Sridharan K, Sivaramakrishnan G, Gnanaraj J. Pharmacological interventions for stress ulcer prophylaxis in critically ill patients: a mixed treatment comparison network meta-analysis and a recursive cumulative meta-analysis. Expert Opin Pharmacother 2017; 19:151-158. [DOI: 10.1080/14656566.2017.1419187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Gowri Sivaramakrishnan
- Prosthodontics, School of Oral Health, College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
| | - Jerome Gnanaraj
- Department of Medicine, Johns Hopkins Bayview Medical Center, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Alhazzani W, Alshamsi F, Belley-Cote E, Heels-Ansdell D, Brignardello-Petersen R, Alquraini M, Perner A, Møller MH, Krag M, Almenawer S, Rochwerg B, Dionne J, Jaeschke R, Alshahrani M, Deane A, Perri D, Thebane L, Al-Omari A, Finfer S, Cook D, Guyatt G. Efficacy and safety of stress ulcer prophylaxis in critically ill patients: a network meta-analysis of randomized trials. Intensive Care Med 2017; 44:1-11. [PMID: 29199388 PMCID: PMC5770505 DOI: 10.1007/s00134-017-5005-8] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 11/24/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE Stress ulcer prophylaxis (SUP) is commonly prescribed in the intensive care unit. However, data from systematic reviews and conventional meta-analyses are limited by imprecision and restricted to direct comparisons. We conducted a network meta-analysis of randomized clinical trials (RCTs) to examine the safety and efficacy of drugs available for SUP in critically ill patients. METHODS We searched MEDLINE, EMBASE, and the Cochrane Library Central Register of Controlled Trials through April 2017 for randomized controlled trials that examined the efficacy and safety of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), and sucralfate for SUP in critically ill patients. No date or language restrictions were applied. Data on study characteristics, methods, outcomes, and risk of bias were abstracted by two reviewers. RESULTS Of 96 potentially eligible studies, we included 57 trials enrolling 7293 patients. The results showed that PPIs are probably more effective for preventing clinically important gastrointestinal bleeding (CIB) than H2RAs [odds ratio (OR) 0.38; 95% confidence interval (95% CI) 0.20, 0.73], sucralfate (OR 0.30; 95% CI 0.13, 0.69), and placebo (OR 0.24; 95% CI 0.10, 0.60) (all moderate quality evidence). There were no convincing differences among H2RA, sucralfate, and placebo. PPIs probably increase the risk of developing pneumonia compared with H2RAs (OR 1.27; 95% CI 0.96, 1.68), sucralfate (OR 1.65; 95% CI 1.20, 2.27), and placebo (OR 1.52; 95% CI 0.95, 2.42) (all moderate quality). Mortality is probably similar across interventions (moderate quality). Estimates of baseline risks of bleeding varied significantly across studies, and only one study reported on Clostridium difficile infection. Definitions of pneumonia varied considerably. Most studies on sucralfate predate pneumonia prevention strategies. CONCLUSIONS Our results provide moderate quality evidence that PPIs are the most effective agents in preventing CIB, but they may increase the risk of pneumonia. The balance of benefits and harms leaves the routine use of SUP open to question.
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Affiliation(s)
- Waleed Alhazzani
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada. .,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, UAE University, Al Ain, United Arab Emirates
| | - Emilie Belley-Cote
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | | | - Mustafa Alquraini
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Mette Krag
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Saleh Almenawer
- Department of Surgery, McMaster University, Hamilton, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Joanna Dionne
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada
| | - Roman Jaeschke
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | | | - Adam Deane
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Dan Perri
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada
| | - Lehana Thebane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Awad Al-Omari
- Department of Critical Care, Security Forces Hospital, Riyadh, Saudi Arabia.,Department of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Simon Finfer
- The George Institute for Global Health and Royal North Shore Hospital, University of Sydney, Sydney, NSW, Australia
| | - Deborah Cook
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Gordon Guyatt
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
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Schoergenhofer C, Hobl EL, Schellongowski P, Heinz G, Speidl WS, Siller-Matula JM, Schmid M, Sunder-Plaßmann R, Stimpfl T, Hackl M, Jilma B. Clopidogrel in Critically Ill Patients. Clin Pharmacol Ther 2017; 103:217-223. [PMID: 28913918 PMCID: PMC5813104 DOI: 10.1002/cpt.878] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 08/21/2017] [Accepted: 09/05/2017] [Indexed: 12/13/2022]
Abstract
Only limited data are available regarding the treatment of critically ill patients with clopidogrel. This trial investigated the effects and the drug concentrations of the cytochrome P450 (CYP450) activated prodrug clopidogrel (n = 43) and the half‐life of the similarly metabolized pantoprazole (n = 16) in critically ill patients. ADP‐induced aggregometry in whole blood classified 74% (95% confidence intervals 59–87%) of critically ill patients as poor responders (n = 43), and 65% (49–79%) responded poorly according to the vasodilator‐stimulated phosphoprotein phosphorylation (VASP‐P) assay. Although the plasma levels of clopidogrel active metabolite normally exceed the inactive prodrug ∼30‐fold, the parent drug levels even exceeded those of the metabolite 2‐fold in critically ill patients. The half‐life of pantoprazole was several‐fold longer in these patients compared with reference populations. The inverse ratio of prodrug/active metabolite indicates insufficient metabolization of clopidogrel, which is independently confirmed by the ∼5‐fold increase in half‐life of pantoprazole. Thus, high‐risk patients may benefit from treatment with alternative platelet inhibitors.
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Affiliation(s)
| | - Eva-Luise Hobl
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Peter Schellongowski
- Department of Medicine I, Hematology, and Oncology, Medical University of Vienna, Vienna, Austria
| | - Gottfried Heinz
- Department of Medicine II, Cardiology, Medical University of Vienna, Vienna, Austria
| | - Walter S Speidl
- Department of Medicine II, Cardiology, Medical University of Vienna, Vienna, Austria
| | | | - Monika Schmid
- Department of Medicine III, Gastroenterology, and Hepatology, Medical University of Vienna, Vienna, Austria
| | | | - Thomas Stimpfl
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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63
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Buendgens L, Tacke F. Do we still need pharmacological stress ulcer prophylaxis at the ICU? J Thorac Dis 2017; 9:4201-4204. [PMID: 29268471 DOI: 10.21037/jtd.2017.09.121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Lukas Buendgens
- Department of Medicine III, University Hospital Aachen, Aachen, Germany
| | - Frank Tacke
- Department of Medicine III, University Hospital Aachen, Aachen, Germany
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64
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Mourani PM, Sontag MK. Ventilator-Associated Pneumonia in Critically Ill Children: A New Paradigm. Pediatr Clin North Am 2017; 64:1039-1056. [PMID: 28941534 DOI: 10.1016/j.pcl.2017.06.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Ventilator-associated pneumonia (VAP) is a serious complication of critical illness. Surveillance definitions have undergone revisions for more objective and consistent reporting. The 1 organism-1 disease paradigm for microbial involvement may not adequately apply to many cases of VAP, in which pathogens are introduced to a pre-existing and often complex microbial community that facilitates or hinders the potential pathogen, consequently determining whether progression to VAP occurs. As omics technology is applied to VAP, a paradigm is emerging incorporating simultaneous assessments of microbial populations and their activity, as well as the host response, to personalize prevention and treatment.
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Affiliation(s)
- Peter M Mourani
- Section of Critical Care, Department of Pediatrics, University of Colorado Denver, School of Medicine, Children's Hospital Colorado, 13121 East 17th Avenue, MS8414, Aurora, CO 80045, USA.
| | - Marci K Sontag
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Denver Anschutz Medical Campus, 13001 East 17th, B119, Aurora, CO 80045, USA
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65
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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: 4.6] [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.
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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
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Withholding Pantoprazole for Stress Ulcer Prophylaxis in Critically Ill Patients: A Pilot Randomized Clinical Trial and Meta-Analysis. Crit Care Med 2017; 45:1121-1129. [PMID: 28459708 DOI: 10.1097/ccm.0000000000002461] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION A decreased frequency of upper gastrointestinal bleeding and a possible association of proton pump inhibitor use with Clostridium difficile and ventilator-associated pneumonia have raised concerns recently. The Reevaluating the Inhibition of Stress Erosions Pilot Trial determined the feasibility of undertaking a larger trial investigating the efficacy and safety of withholding proton pump inhibitors in critically ill patients. METHODS In 10 ICUs, we randomized adult ICU patients anticipated to be mechanically ventilated for greater than or equal to 48 hours to receive 40 mg of IV pantoprazole daily or placebo. We excluded patients who had acute or recent gastrointestinal bleed, used dual antiplatelet agents, had a medical condition requiring proton pump inhibitor treatment, or had already received more than one dose of acid suppression daily. Patients, families, clinicians, and research staff were blinded. We conducted a systematic review and meta-analysis of similar trials. MAIN RESULTS Ninety-one patients (49 pantoprazole and 42 placebo) from 10 centers in Canada, Saudi Arabia, and Australia were enrolled. All feasibility goals were met: 1) recruitment rate was 2.6 patients per month; 2) consent rate was 77.8%; and 3) protocol adherence was 97.7%. Upper gastrointestinal bleeding developed in 6.1% of patients in the pantoprazole group and 4.8% in the placebo group (p = 1.0). Ventilator-associated pneumonia developed in 20.4% of patients in the pantoprazole group and 14.3% in the placebo group (p = 0.58). C. difficile was identified in 4.1% pantoprazole patients and in 2.4% placebo patients (p = 1.0). We meta-analyzed five trials (604 patients) of proton pump inhibitors versus placebo; there was no statistically significant difference in the risk of upper gastrointestinal bleeding, infections, or mortality. CONCLUSIONS Our results support the feasibility of a larger trial to evaluate the safety of withholding stress ulcer prophylaxis. Although the results are imprecise, there was no alarming increase in the risk of upper gastrointestinal bleeding; the effect of proton pump inhibitors on ventilator-associated pneumonia and C. difficile remain unclear.
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Marker S, Perner A, Wetterslev J, Barbateskovic M, Jakobsen JC, Krag M, Granholm A, Anthon CT, Møller MH. Stress ulcer prophylaxis versus placebo or no prophylaxis in adult hospitalised acutely ill patients-protocol for a systematic review with meta-analysis and trial sequential analysis. Syst Rev 2017; 6:118. [PMID: 28646925 PMCID: PMC5483291 DOI: 10.1186/s13643-017-0509-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Stress ulcer prophylaxis is considered standard of care in many critically ill patients in the intensive care unit (ICU). However, the quality of evidence supporting this has recently been questioned, and clinical equipoise exists. Whether there is overall benefit or harm of stress ulcer prophylaxis in adult hospitalised acutely ill patients is unknown. Accordingly, we aim to assess patient-important benefits and harms of stress ulcer prophylaxis versus placebo or no treatment in adult hospitalised acutely ill patients with high risk of gastrointestinal bleeding irrespective of hospital setting. METHODS/DESIGN We will conduct a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis and assess use of proton pump inhibitors (PPIs) or histamine-2-receptor antagonists (H2RAs) in any dose, formulation and duration. We will accept placebo or no prophylaxis as control interventions. The participants will be adult hospitalised acutely ill patients with high risk of gastrointestinal bleeding. We will systematically search the Cochrane Library, MEDLINE, EMBASE, Science Citation Index, BIOSIS and Epistemonikos for relevant literature. We will follow the recommendations by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. The risk of systematic errors (bias) and random errors will be assessed, and the overall quality of evidence will be evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. DISCUSSION There is a need for a high-quality systematic review to summarise the benefits and harms of stress ulcer prophylaxis in hospitalised patients to inform practice and future research. Although stress ulcer prophylaxis is used worldwide, no firm evidence for benefit or harm as compared to placebo or no treatments has been established. Critical illness is a continuum not limited to the ICU setting, which is why it is important to assess the benefits and harms of stress ulcer prophylaxis in a wider perspective than exclusively in ICU patients. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017055676.
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Affiliation(s)
- Søren Marker
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark. .,Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark.
| | - Anders Perner
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark.,Department of Cardiology, Holbaek Hospital, Holbaek, Denmark
| | - Mette Krag
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Anders Granholm
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Carl Thomas Anthon
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
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Marker S, Krag M, Møller MH. What's new with stress ulcer prophylaxis in the ICU? Intensive Care Med 2017; 43:1132-1134. [PMID: 28238056 DOI: 10.1007/s00134-017-4733-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/16/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Søren Marker
- Department of Intensive Care, 4131, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Mette Krag
- Department of Intensive Care, 4131, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, 4131, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
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Ovenden C, Plummer MP, Selvanderan S, Donaldson TA, Nguyen NQ, Weinel LM, Finnis ME, Summers MJ, Ali Abdelhamid Y, Chapman MJ, Rayner CK, Deane AM. Occult upper gastrointestinal mucosal abnormalities in critically ill patients. Acta Anaesthesiol Scand 2017; 61:216-223. [PMID: 27966213 DOI: 10.1111/aas.12844] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/18/2016] [Accepted: 11/15/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND The objectives of this study were to estimate the frequency of occult upper gastrointestinal abnormalities, presence of gastric acid as a contributing factor, and associations with clinical outcomes. METHODS Data were extracted for study participants at a single centre who had an endoscopy performed purely for research purposes and in whom treating physicians were not suspecting gastrointestinal bleeding. Endoscopic data were independently adjudicated by two gastroenterologists who rated the likelihood that observed pathological abnormalities were related to gastric acid secretion using a 3-point ordinal scale (unlikely, possible or probable). RESULTS Endoscopy reports were extracted for 74 patients [age 52 (37, 65) years] undergoing endoscopy on day 5 [3, 9] of ICU admission. Abnormalities were found in 25 (34%) subjects: gastritis/erosions in 10 (14%), nasogastric tube trauma in 8 (11%), oesophagitis in 4 (5%) and non-bleeding duodenal ulceration in 3 (4%). The contribution of acid secretion to observed pathology was rated 'probable' in six subjects (rater #1) and five subjects (rater #2). Prior to endoscopy, 39 (53%) patients were receiving acid-suppressive therapy. The use of acid-suppressive therapy was not associated with the presence of an endoscopic abnormality (present 15/25 (60%) vs. absent 24/49 (49%); P = 0.46). Haemoglobin concentrations, packed red cells transfused and mortality were not associated with mucosal abnormalities (P = 0.83, P > 0.9 and P > 0.9 respectively). CONCLUSIONS Occult mucosal abnormalities were observed in one-third of subjects. The presence of mucosal abnormalities appeared to be independent of prior acid-suppressive therapy and was not associated with reduced haemoglobin concentrations, increased transfusion requirements, or mortality.
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Affiliation(s)
- C. Ovenden
- Discipline of Acute Care Medicine; University of Adelaide; Adelaide SA Australia
| | - M. P. Plummer
- Discipline of Acute Care Medicine; University of Adelaide; Adelaide SA Australia
- Neurosciences Critical Care Unit; Addenbrooke's Hospital; Cambridge UK
| | - S. Selvanderan
- Discipline of Acute Care Medicine; University of Adelaide; Adelaide SA Australia
| | - T. A. Donaldson
- Department of Anaesthesia; Royal Adelaide Hospital; Adelaide SA Australia
| | - N. Q. Nguyen
- Centre for Research Excellence in Translating Nutritional Science to Good Health; Adelaide SA Australia
- Discipline of Medicine; University of Adelaide; Adelaide SA Australia
- Department of Gastroenterology and Hepatology; Royal Adelaide Hospital; Adelaide SA Australia
| | - L. M. Weinel
- Department of Critical Care Services; Royal Adelaide Hospital; Adelaide SA Australia
| | - M. E. Finnis
- Discipline of Acute Care Medicine; University of Adelaide; Adelaide SA Australia
- Department of Critical Care Services; Royal Adelaide Hospital; Adelaide SA Australia
| | - M. J. Summers
- Department of Critical Care Services; Royal Adelaide Hospital; Adelaide SA Australia
| | - Y. Ali Abdelhamid
- Discipline of Acute Care Medicine; University of Adelaide; Adelaide SA Australia
| | - M. J. Chapman
- Discipline of Acute Care Medicine; University of Adelaide; Adelaide SA Australia
- Centre for Research Excellence in Translating Nutritional Science to Good Health; Adelaide SA Australia
- Department of Critical Care Services; Royal Adelaide Hospital; Adelaide SA Australia
| | - C. K. Rayner
- Centre for Research Excellence in Translating Nutritional Science to Good Health; Adelaide SA Australia
- Discipline of Medicine; University of Adelaide; Adelaide SA Australia
- Department of Gastroenterology and Hepatology; Royal Adelaide Hospital; Adelaide SA Australia
| | - A. M. Deane
- Discipline of Acute Care Medicine; University of Adelaide; Adelaide SA Australia
- Department of Critical Care Services; Royal Adelaide Hospital; Adelaide SA Australia
- Intensive Care Unit; The Royal Melbourne Hospital; Parkville Vic. Australia
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