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Redepenning DH, Maddali S, Glotfelty-Scheuering OA, Berry JB, Dicianno BE. Incidence, timing, and risk factors for development of gastrointestinal bleeding in acute traumatic spinal cord injury: A systematic review. J Spinal Cord Med 2024:1-11. [PMID: 39173126 DOI: 10.1080/10790268.2024.2391593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2024] Open
Abstract
CONTEXT Current guidelines recommend four weeks of stress ulcer prophylaxis following traumatic spinal cord injury. OBJECTIVES Assess the current literature on the incidence, timing, and risk factors for gastrointestinal bleeding/clinically important gastrointestinal bleeding in the acute setting following a traumatic spinal cord injury and whether the use of stress ulcer prophylaxis has been shown to reduce the rates of gastrointestinal bleeding. METHODS A systematic review was performed in PubMed, Embase, Web of Science, and Cochrane Library following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. RESULTS A total of 24 articles met the inclusion/exclusion criteria. The average rate of gastrointestinal bleeding among all studies was 5.5% (95% CI = 5.4-5.6%; n = 26,576). The average rate of clinically important gastrointestinal bleeding was 1.8% (95% CI = 1.79-1.82%; n = 3,857). The mean time since injury to when gastrointestinal bleeding occurred ranged from 5 to 22.5 days. For clinically important gastrointestinal bleeding the average time was 16 days or less. Those with cervical injuries had a higher incidence of clinically important gastrointestinal bleeding compared to those with non-cervical injuries (2.7% vs. 0.7%). No study found any difference in the use of stress ulcer prophylaxis in participants with or without gastrointestinal bleeding. CONCLUSIONS The overall incidence of clinically important gastrointestinal bleeding among studies was found to be low. Individuals with non-cervical injury were not found to be at high risk of clinically important gastrointestinal bleeding. There was also insufficient evidence to indicate that use of stress ulcer prophylaxis reduces the rate of gastrointestinal bleeding in those with traumatic spinal cord injury.
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Affiliation(s)
- Drew H Redepenning
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Shivaali Maddali
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Olivia A Glotfelty-Scheuering
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jessica B Berry
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Brad E Dicianno
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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Lee TC, Goodwin Wilson M, Lawandi A, McDonald EG. Proton Pump Inhibitors Versus Histamine-2 Receptor Antagonists Likely Increase Mortality in Critical Care: An Updated Meta-Analysis. Am J Med 2021; 134:e184-e188. [PMID: 32931766 DOI: 10.1016/j.amjmed.2020.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Upper gastrointestinal bleeding is common among the critically ill. Recently, the Proton Pump Inhibitors (PPIs) vs. Histamine-2 Receptor Blockers for Ulcer Prophylaxis Therapy in the Intensive Care Unit (PEPTIC) trial suggested PPIs might increase mortality. We performed an updated meta-analysis to further inform discussion. METHODS We leveraged 2 recent systematic reviews to identify randomized controlled trials directly comparing PPIs and H-2 Receptor Antagonists (H2RAs) for stress ulcer prophylaxis in critically ill patients and reporting mortality. We extracted mortality data from each study and meta-analyzed them with the PEPTIC trial using a random effects model. RESULTS Of 28,559 total patients, 14,436 (50.5%) were allocated to PPI and 14,123 to H2RAs (49.5%). Compared to H2RAs, the pooled relative risk for mortality was 1.05 (95% confidence interval 1.00-1.10) with an estimated risk difference for mortality of 9 additional deaths per 1000 patients exposed to PPI (95% confidence interval 0-18); heterogeneity was low (I2 = 0%; P = 0.826). CONCLUSIONS Stress ulcer prophylaxis with PPIs likely increases mortality compared to H2RAs. Whether stress ulcer prophylaxis is beneficial in critical care remains open to further study.
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Affiliation(s)
- Todd C Lee
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montréal, Québec, Canada; Centre for Outcomes Research and Evaluation (CORE), Department of Medicine, Research Institute, McGill University Health Centre, Montréal, Québec, Canada.
| | - Marnie Goodwin Wilson
- Division of General Internal Medicine, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Alexander Lawandi
- Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Md
| | - Emily G McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montréal, Québec, Canada; Centre for Outcomes Research and Evaluation (CORE), Department of Medicine, Research Institute, McGill University Health Centre, Montréal, Québec, Canada
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Singh-Franco D, Mastropietro DR, Metzner M, Dressler MD, Fares A, Johnson M, De La Rosa D, Wolowich WR. Impact of pharmacy-supported interventions on proportion of patients receiving non-indicated acid suppressive therapy upon discharge: A systematic review and meta-analysis. PLoS One 2020; 15:e0243134. [PMID: 33270710 PMCID: PMC7714117 DOI: 10.1371/journal.pone.0243134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 11/16/2020] [Indexed: 12/13/2022] Open
Abstract
Objective Conduct a systematic review and meta-analysis to estimate the impact of pharmacy-supported interventions on the proportion of patients discharged from the hospital on inappropriate acid suppressive therapy (AST). Methods To identify studies, the following databases were systematically searched on October 14th, 2018 and repeated on September 12th, 2019: Ovid MEDLINE(R) and In-Process & Other Non-Indexed Citations and Daily, Embase.com, CINAHL, Web of Science, Cochrane CENTRAL (EBSCO), and ClinicalTrials.gov. Eligible studies consisted of adults, intervention and historical/usual care groups, description of active pharmacy-supported intervention, and proportion of patients discharged on inappropriate AST. Qualitative assessments and quantitative analyses were performed. Modified funnel plot analysis assessed heterogeneity. Preferred reporting items of systematic reviews and meta-analyses (PRISMA) methodology was used to evaluate studies in this review. Results Seventeen publications resulting in 16 studies were included in the review. Using random effects model, meta-analysis showed a significant reduction in the odds of being discharged on inappropriate AST from the hospital in the pharmacist-supported intervention arm versus comparator (Odds Ratio 0.33 [95%CI 0.20 to 0.53]), with significant heterogeneity (I2 = 86%). Eleven studies favored pharmacy-supported interventions, four were inconclusive and one favored usual care. Using modified funnel plot analysis, our final evaluation was distilled to 11 studies and revealed a similar outcome (OR 0.36 [95%CI 0.27 to 0.48]), but with less heterogeneity (I2 = 36%). Conclusion This systematic review and meta-analysis showed that pharmacy-supported interventions were associated with a significantly reduced probability of patients discharged on inappropriate AST. However, heterogeneity was high and may affect interpretation of results. Using funnel plot optimization method, three positive and two negative studies were objectively removed from analyses, resulting in a similar effect size, but with less heterogeneity. To improve study quality, future researchers should consider utilizing a pre-post, multi-arm, prospective design with sampling randomization, training of data extractors (preferably two extractors), re-evaluating a small dataset to check for agreement and providing a comprehensive methodology in subsequent publications.
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Affiliation(s)
- Devada Singh-Franco
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
- * E-mail:
| | - David R. Mastropietro
- Department of Pharmaceutical Sciences, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Miriam Metzner
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
| | - Michael D. Dressler
- Department of Pharmaceutical Sciences, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Amneh Fares
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
| | - Melinda Johnson
- Martin and Gail Press Health Professions Division Library, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Daisy De La Rosa
- Martin and Gail Press Health Professions Division Library, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - William R. Wolowich
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
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Chen Z, Huang H, Yang J, Cai H, Yu Y. The diagnostic value of magnetic resonance urography for detecting ureteric obstruction: a systematic review and meta-analysis. Ann Med 2020; 52:275-282. [PMID: 32233669 PMCID: PMC7877960 DOI: 10.1080/07853890.2020.1741672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of magnetic resonance urography (MRU) and determine its value for detecting ureteric obstruction. METHODS The electronic databases, including PubMed, Embase and the Cochrane library, were systematically searched for studies published throughout September 2018. The summary of sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and receiver operating characteristic (ROC) curves was assessed to evaluate the diagnostic accuracy of MRU. Subgroup analyses were conducted based on the mean age of the included patients (adults or children). RESULTS Eight studies with a total of 594 patients were included. The summary of the sensitivity and specificity of MRU for diagnosing ureteric obstruction was 0.94 and 0.87, respectively. Furthermore, the pooled PLR and NLR were 7.33 and 0.07, respectively. The DOR of MRU for detecting ureteric obstruction was 95.12. In addition, the summary of the area under the ROC of MRU was 0.96. Finally, the specificity, PLR and area under the ROC of MRU for diagnosing ureteric obstruction in adults were higher than children, while the sensitivity of MRU in adults was lower than children. CONCLUSIONS These findings suggested a relatively high diagnostic value of MRU for detecting ureteric obstruction. Moreover, the diagnostic accuracy of MRU in adults was higher than in children. KEY MESSAGE Magnetic resonance urography (MRU) in detecting ureteric obstruction has relatively better sensitivity, specificity, PLR, NLR, DOR and AUC. The diagnostic value, including specificity, PLR and AUC of MRU in adults, was higher than in children, while the sensitivity of MRU in adults was lower than in children.
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Affiliation(s)
- Zhongping Chen
- Department of Medical Imaging, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Huayu Huang
- Department of Medical Imaging, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Jun Yang
- Department of Medical Imaging, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Hongtao Cai
- Department of Medical Imaging, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Yali Yu
- Department of Medical Imaging, Shenzhen Longhua District Central Hospital, Shenzhen, China
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Abstract
PURPOSE OF REVIEW Change of practice in the ICU, particularly the discontinuation of approaches, which are no longer felt to be beneficial, can be challenging. This review will examine this issue and outline current thinking regarding how to best approach it. RECENT FINDINGS Practices in medicine that do not provide patients benefit and possibly cause harm exist throughout medicine and are called low-value practices. Some low-value practices have successfully been removed from the ICU whereas others remain. The process of removing these practices from established care is often called deadoption. Low-value practices that are simply ineffective but produce comparatively less harm or cost, may represent a significant challenge to deadoption. Additionally, although no single intervention has been identified as the preferred method of deadoption of a low-value practice, we advocate for a multimodal approach. SUMMARY Deadoption in the intensive care unit of practices that either cause harm or are significantly costly relative to their benefit remains an elusive goal. Attempts at deadoption should target local ICU circumstances, while still encompassing the spectrum of care outside the ICU, engage nursing more fully, promote the use of local champions, especially peers, and recognize the requirement to seek sustainability.
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Abstract
PURPOSE OF REVIEW Stress ulcer prophylaxis in critically-ill patients has been a subject of extensive research, with multiple clinical trials attempting to study the best method of stress ulcer prophylaxis with the least adverse effects. Until recently, pharmacologic prophylaxis has prevailed as the primary choice for the prevention of stress ulcers but recent clinical studies have attempted to evaluate the role of enteral nutrition in stress ulcer prophylaxis. RECENT FINDINGS The incidence of stress ulcers that result in clinically important gastrointestinal bleeding (CIGIB) has drastically decreased over the last two decades. Furthermore, in the current era CIGB in the ICU does not seem to be associated with an increased mortality. Multiple recent clinical studies aimed to evaluate the role of proton pump inhibitors (PPIs) in patients who tolerate enteral nutrition in the ICU. SUMMARY The results of multiple recent clinical studies call for re-evaluation of the routine use of PPIs in critically ill patients who tolerates enteral nutrition in the ICU. Despite the promising preliminary results, definitive recommendations need larger clinical trials that are powered to evaluate any added benefits of using PPI in critically ill patients who tolerate enteral nutrition given the low incidence of CIGB in the current era.
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Liu Y, Li D, Wen A. Pharmacologic Prophylaxis of Stress Ulcer in Non-ICU Patients: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials. Clin Ther 2020; 42:488-498.e8. [PMID: 32046894 DOI: 10.1016/j.clinthera.2020.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 01/07/2020] [Accepted: 01/14/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Acid-suppressive medications are widely used in non-intensive care unit (non-ICU) patients for stress ulcer (SU) prophylaxis. However, SU prophylaxis in this population is still controversial. The purpose of this study was to systematically evaluate the efficacy and tolerability of these agents for SU prophylaxis in non-ICU patients. METHODS Electronic databases including Cochrane, ClinicalTrials.gov, Ovid-Medline, Embase, Chinese CNKI, and Wanfang Data were systematically searched on July 10, 2019, for randomized controlled trials (RCTs) that evaluated acid-suppressive medications in non-ICU patients. Network meta-analysis and pairwise meta-analysis were performed to calculate odds ratios (ORs) and 95% CIs. A random-effects model was used for generating pooled estimates. The primary outcome was occurrence of SU bleeding, and the adverse drug events (ADEs) were described as the secondary outcome. FINDINGS A total of 17 RCTs involving 1985 patients were eligible. Meta-analysis results indicated that the occurrence of SU bleeding was significantly decreased with all acid-suppressive medications compared with placebos (gastric mucosa protectants, OR = 0.29 [95% CI, 0.14-0.61]; H2-receptor antagonists, OR = 0.3 [95% CI, 0.18-0.50]; proton pump inhibitors [PPIs]: OR = 0.08 [95% CI, 0.04-0.16]). The occurrence of SU bleeding was significantly decreased with PPIs compared with gastric mucosa protectants (OR = 0.29; 95% CI, 0.12-0.72) and H2-receptor antagonists (OR = 0.28; 95% CI, 0.16-0.48). There was no significant difference between any 2 classes of PPIs on SU bleeding or any 2 acid-suppressive medications on ADEs. IMPLICATIONS PPIs could significantly decrease SU bleeding risk without increasing ADEs than other acid-suppressive medications for SU prophylaxis in non-ICU patients. However, RCTs of high quality were required to confirm the findings of this investigation.
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Affiliation(s)
- Yi Liu
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Dandan Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Aiping Wen
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
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Snapshot of proton pump inhibitors prescriptions in a tertiary care hospital in Switzerland: less is more? Int J Clin Pharm 2019; 41:1634-1641. [DOI: 10.1007/s11096-019-00929-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 10/17/2019] [Indexed: 12/11/2022]
Abstract
Abstract
Background Proton pump inhibitors are among the most widely prescribed drugs in the world, but more than half of the indications for prescription are unjustified. The misuse of this therapeutic class has heavy consequences such as additional health costs, adverse drug reactions following long-term use and gastric acid rebound when the proton pump inhibitor is discontinued. Objective The overprescription of proton pump inhibitors is therefore becoming a public health problem, which led us to evaluate their use within the Geneva University Hospitals. Setting Patients hospitalized in two divisions of the department of internal medicine of the Geneva University Hospitals on a single day. Methods This is a register-based cross-sectional study and it collected data about the prescription pattern of proton pump inhibitors by consulting the electronic records of patients included. Main outcome measure To determine if the proton pump inhibitors prescription is made according to the market authorization and the available guidelines. Results Hundred-eighty patients were included. 54% of patients were on proton pump inhibitors, 29% of whom had their treatment initiated at hospital. Of the indications for treatment, 72% were not justified and 63% of the justified indications did not have an adequate dosage. Therefore, in all patients with a proton pump inhibitor at hospital, only 11% had a justified indication with an adequate dose. Finally, 87% of known home prescriptions were renewed on admission and among them, 71% did not have a justified or possibly justified indication according to the guidelines. Conclusion Indication for treatment inside the hospital was not justified in 72% of patients and only 11% had a justified indication with an adequate dosage. Precise guidelines with evidence-based indications and adequate daily doses would help to correctly prescribe proton pump inhibitors. Moreover, patients should benefit from a thorough evaluation of their treatment.
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Alshami A, Barona SV, Varon J, Surani S. Gastrointestinal stress ulcer prophylaxis in the intensive care unit, where is the data? World J Meta-Anal 2019; 7:72-76. [DOI: 10.13105/wjma.v7.i3.72] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 03/28/2019] [Accepted: 03/28/2019] [Indexed: 02/06/2023] Open
Abstract
Stress-induced gastrointestinal ulcers are common among patients admitted to the intensive care unit (ICU). These ulcers impose significant morbidity and mortality, therefore, stress ulcer prophylaxis (SUP) is a common clinical practice among healthcare providers dealing with these critically-ill patients. Several strategies for SUP have been suggested over the past four decades, with acid suppressive therapies being the most commonly used in the ICU. Whether SUP is effective and safe, or not, remains a topic of controversy. The data is still conflicting, and provision of a simple answer is not feasible at the present time. Recently, a large phase IV, multicenter, randomized clinical trial (SUP-ICU), negated the benefits (and harms) of proton pump inhibitors as SUP. This article reviews some of these controversies.
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Affiliation(s)
- Abbas Alshami
- Dorrington Medical Associates, Houston, TX 77030, United States
- University of Baghdad College of Medicine, Baghdad 12114, Iraq
| | - Sheily Vianney Barona
- Dorrington Medical Associates, Houston, TX 77030, United States
- Benemerita Universidad Autonoma de Puebla, Puebla 72000, Mexico
| | - Joseph Varon
- United General Hospital, 7501 Fanin Street Houston, TX 77054, United States
- Critical Care Services, United Memorial Medical Center, Houston, TX 77091, United States
- Acute and Continuing Care, University of Texas Health Science Center at Houston, Houston, TX 77030, United States
- Medicine, University of Texas Medical Branch at Galveston Houston, Galveston, TX 77555, United States
| | - Salim Surani
- Department of Pulmonary, Critical Care and Sleep Medicine, Texas A&M University, Health Science Center, Bryan, TX 77807, United States
- Pulmonary and Critical Care Fellowship Program, Bay Area Medical Center, Marinette, WI 54143, United States
- Medical Critical Care Services, Christus Spohn Hospitals-Corpus Christi, Corpus Christi, TX 78404, United States
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Affiliation(s)
- Alison M. Stevens
- St. Louis College of Pharmacy, Clinical Pharmacy Specialist, St. Luke's Hospital
| | - Zachariah Thomas
- Ernest Mario School of Pharmacy, Rutgers, the State University of New Jersey and Clinical Pharmacist, Hackensack University Medical Center
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Kumar S, Ramos C, Garcia-Carrasquillo RJ, Green PH, Lebwohl B. Incidence and risk factors for gastrointestinal bleeding among patients admitted to medical intensive care units. Frontline Gastroenterol 2017; 8:167-173. [PMID: 28839905 PMCID: PMC5558277 DOI: 10.1136/flgastro-2016-100722] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 07/11/2016] [Accepted: 07/18/2016] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES To identify incidence and risk factors for new-onset gastrointestinal bleeding (GIB) in a medical intensive care unit (ICU), a topic for which there is a paucity of recent studies. DESIGN Retrospective cohort study. SETTING Medical ICUs at our tertiary-care hospital, from 2007 to 2013. PATIENTS Patients who developed clinically significant GIB after entering the ICU. INTERVENTIONS Univariable and multivariable analyses. MAIN OUTCOME MEASURES Incidence and risk factors for development of GIB. RESULTS 4439 patients entered the medical ICU without a pre-existing GIB and 58 (1.3%) developed GIB while in the ICU. Risk factors included length of ICU stay (OR per additional day 1. 06; 95% CI 1.04 to 1.09) and elevated creatinine on ICU admission (OR 2.35; 95% CI 1.18 to 4.68, p=0.02). Elevated bilirubin on ICU admission (OR 2.08; 95% CI 0.97 to 4.47, p=0.06), and elevated aspartate transaminase (AST) on ICU admission (OR 2.20; 95% CI 0.96 to 5.03, p=0.06) trended towards increased risk of GIB that did not meet statistical significance. Age, gender, admission coagulation studies and mechanical ventilation were not predictive of GIB. Among those patients with new-onset GIB in the ICU, 47% died during that hospitalisation, as compared with those 30% of those without a GIB, p<0.01. CONCLUSIONS Onset of GIB is now an infrequent occurrence in the ICU setting; however those with elevated bilirubin, AST and creatinine upon admission, and with longer length of ICU stay appear at increased risk and may benefit from closer monitoring.
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Affiliation(s)
- Shria Kumar
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Christopher Ramos
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Reuben J Garcia-Carrasquillo
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Peter H Green
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Benjamin Lebwohl
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, New York, USA,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
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Palm NM, McKinzie B, Ferguson PL, Chapman E, Dorlon M, Eriksson EA, Jewett B, Leon SM, Privette AR, Fakhry SM. Pharmacologic Stress Gastropathy Prophylaxis May Not Be Necessary in At-Risk Surgical Trauma ICU Patients Tolerating Enteral Nutrition. J Intensive Care Med 2016; 33:424-429. [PMID: 27837045 DOI: 10.1177/0885066616678385] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Stress gastropathy is a rare complication of the intensive care unit stay with high morbidity and mortality. There are data that support the concept that patients tolerating enteral nutrition have sufficient gut blood flow to obviate the need for prophylaxis; however, no robust studies exist. This study assesses the incidence of clinically significant gastrointestinal bleeding in surgical trauma intensive care unit (STICU) patients at risk of stress gastropathy secondary to mechanical ventilation receiving enteral nutrition without pharmacologic prophylaxis. DESIGN A retrospective cohort study of records from 2008 to 2013. SETTING Adult patients in a single-center STICU were included. PATIENTS Patients were included if they received full enteral nutrition while on mechanical ventilation. Exclusion criteria were coagulopathy, glucocorticoid use, prior-to-admission acid-suppressive therapy use, direct trauma or surgery to the stomach, failure to tolerate goal enteral nutrition, orders to allow natural death, and deviation from the intervention. INTERVENTION Pharmacologic stress ulcer prophylaxis was discontinued once enteral nutrition was providing full caloric requirements for patients requiring mechanical ventilation. MEASUREMENTS AND MAIN RESULTS A total of 200 patients were included. The median age was 42 years, 83.0% were male, and 96.0% were trauma patients. The incidence of clinically significant gastrointestinal bleeding was 0.50%, with a subset analysis of traumatic brain injury patients yielding an incidence of 0.68%. Rates of ventilator-associated pneumonia and Clostridium difficile infection were low at 1.0 case/1000 ventilator days and 0.2 events/1000 patient days, respectively. Hospital all-cause mortality was 2.0%. Cost savings of US$121/patient stay were realized. CONCLUSION Stress gastropathy is rare in this population. Surgical and trauma patients at risk for stress gastropathy did not benefit from continued pharmacologic prophylaxis once they tolerated enteral nutrition. Pharmacologic prophylaxis may safely be discontinued in this patient population. Further investigation is warranted to determine whether continued prophylaxis after attaining enteral feeding goals is detrimental.
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Affiliation(s)
- Nicole M Palm
- 1 Department of Pharmacy, The Cleveland Clinic, Cleveland, OH, USA
| | - Brian McKinzie
- 2 Department of Pharmacy, Medical University of South Carolina, Carolina, Charleston, SC, USA
| | - Pamela L Ferguson
- 3 Department of Surgery, Medical University of South Carolina, Carolina, Charleston, SC, USA
| | - Emily Chapman
- 4 Medical University of South Carolina Health Nutrition Services, Carolina, Charleston, SC, USA
| | - Margaret Dorlon
- 3 Department of Surgery, Medical University of South Carolina, Carolina, Charleston, SC, USA
| | - Evert A Eriksson
- 3 Department of Surgery, Medical University of South Carolina, Carolina, Charleston, SC, USA
| | - Brent Jewett
- 3 Department of Surgery, Medical University of South Carolina, Carolina, Charleston, SC, USA
| | - Stuart M Leon
- 3 Department of Surgery, Medical University of South Carolina, Carolina, Charleston, SC, USA
| | - Alicia R Privette
- 3 Department of Surgery, Medical University of South Carolina, Carolina, Charleston, SC, USA
| | - Samir M Fakhry
- 3 Department of Surgery, Medical University of South Carolina, Carolina, Charleston, SC, USA
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Identifying Risk Factors Associated with Inappropriate Use of Acid Suppressive Therapy at a Community Hospital. Gastroenterol Res Pract 2016; 2016:1973086. [PMID: 27818680 PMCID: PMC5080516 DOI: 10.1155/2016/1973086] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 09/21/2016] [Indexed: 12/11/2022] Open
Abstract
Purpose. By examining the prescribing patterns and inappropriate use of acid suppressive therapy (AST) during hospitalization and at discharge we sought to identify the risk factors associated with such practices. Methods. In this retrospective observational study, inpatient records were reviewed from January 2011 to December 2013. Treatment with AST was considered appropriate if the patient had a known specific indication or met criteria for stress ulcer prophylaxis. Results. In 2011, out of 58 patients who were on AST on admission, 32 were newly started on it and 23 (72%) were inappropriate cases. In 2012, out of 97 patients on AST, 61 were newly started on it and 51 (84%) were inappropriate cases. In 2013, 99 patients were on AST, of which 48 were newly started on it and 36 (75%) were inappropriate cases. 19% of the patients inappropriately started on AST were discharged on it in three years. Younger age, female sex, and 1 or more handoffs between services were significantly associated with increased risk of inappropriate AST. Conclusion. Our findings reflect inappropriate prescription of AST which leads to increase in costs of care and unnecessarily puts the patient at risk for potential adverse events. The results of this study emphasize the importance of examining the patient's need for AST at each level of care especially when the identified risk factors are present.
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Abstract
Stress-related mucosal damage (SRMD) is an erosive process of the gastroduodenum that occurs frequently in critically ill patients. Symptomatic lesions may range from overt bleeding (by hematemesis, melena, bloody or coffee ground aspirates, or hematochezia) to clinically significant hemorrhage (hypotension, tachycardia, or acute anemia requiring transfusion). SRMD is caused by mucosal ischemia that produces an imbalance between injurious factors and the protective mechanisms. Common patient risk factors include mechanical ventilation, coagulopathy, shock, hepatic dysfunction, renal dysfunction, thermal injury, trauma, kidney or liver transplant, head injury or spinal cord injury, recent gastrointestinal hemorrhage, and pharmacologic interventions. Stress ulcer prophylaxis may be provided by administering one of the following pharmacologic agents: an antacid, a histamine2 receptor antagonist, sucralfate, or a proton pump inhibitor. All agents possess equal efficacies but differ in their mechanisms of action, adverse event profile, drug interactions, monitoring requirements, costs, and personnel requirements for preparation and administration. Implementation of institution-specific protocols for stress ulcer prophylaxis provides cost minimization by maximizing appropriate drug usage.
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Affiliation(s)
- Robert MacLaren
- School of Pharmacy, University of Colorado Health Sciences Center, 4200 East Ninth Avenue (C238), Denver, CO 80262,
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Abstract
Catastrophic antiphospholipid syndrome is a rapidly progressive life-threatening disease that causes multiple organ thromboses and dysfunction in the presence of antiphospholipid antibodies. A high index of clinical suspicion and careful investigation are required to make an early diagnosis so that treatment with anticoagulation and corticosteroids can be initiated; plasma exchange and/or intravenous immunoglobulins can be added if the life-threatening condition persists. Despite aggressive treatment and intensive care unit management, patients with catastrophic antiphospholipid syndrome have a 48% mortality rate, primarily attributable to cardiopulmonary failure. This article reviews the current information on the etiopathogenesis, clinical manifestations, diagnosis, management, and prognosis of catastrophic antiphospholipid syndrome.
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Affiliation(s)
- Setu K Vora
- Pulmonary Physicians of Norwich, Norwich, Connecticut, USA
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Lin CC, Hsu YL, Chung CS, Lee TH. Stress ulcer prophylaxis in patients being weaned from the ventilator in a respiratory care center: A randomized control trial. J Formos Med Assoc 2016; 115:19-24. [DOI: 10.1016/j.jfma.2014.10.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 10/20/2014] [Accepted: 10/27/2014] [Indexed: 02/01/2023] Open
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Alexander PE, Bonner AJ, Agarwal A, Li SA, Hariharan A, Izhar Z, Bhatnagar N, Alba C, Akl EA, Fei Y, Guyatt GH, Beyene J. Sensitivity subgroup analysis based on single-center vs. multi-center trial status when interpreting meta-analyses pooled estimates: the logical way forward. J Clin Epidemiol 2015; 74:80-92. [PMID: 26597972 DOI: 10.1016/j.jclinepi.2015.08.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 06/06/2015] [Accepted: 08/31/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Prior studies regarding whether single-center trial estimates are larger than multi-center are equivocal. We examined the extent to which single-center trials yield systematically larger effects than multi-center trials. STUDY DESIGN AND SETTING We searched the 119 core clinical journals and the Cochrane Database of Systematic Reviews for meta-analyses (MAs) of randomized controlled trials (RCTs) published during 2012. In this meta-epidemiologic study, for binary variables, we computed the pooled ratio of ORs (RORs), and for continuous outcomes mean difference in standardized mean differences (SMDs), we conducted weighted random-effects meta-regression and random-effects MA modeling. Our primary analyses were restricted to MAs that included at least five RCTs and in which at least 25% of the studies used each of single trial center (SC) and more trial center (MC) designs. RESULTS We identified 81 MAs for the odds ratio (OR) and 43 for the SMD outcome measures. Based on our analytic plan, our primary analysis (core) is based on 25 MAs/241 RCTs (binary outcome) and 18 MAs/173 RCTs (continuous outcome). Based on the core analysis, we found no difference in magnitude of effect between SC and MC for binary outcomes [RORs: 1.02; 95% confidence interval (CI): 0.83, 1.24; I(2) 20.2%]. Effect sizes were systematically larger for SC than MC for the continuous outcome measure (mean difference in SMDs: -0.13; 95% CI: -0.21, -0.05; I(2) 0%). CONCLUSIONS Our results do not support prior findings of larger effects in SC than MC trials addressing binary outcomes but show a very similar small increase in effect in SC than MC trials addressing continuous outcomes. Authors of systematic reviews would be wise to include all trials irrespective of SC vs. MC design and address SC vs. MC status as a possible explanation of heterogeneity (and consider sensitivity analyses).
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Affiliation(s)
- Paul E Alexander
- Health Research Methods (HRM), Department of Clinical Epidemiology and Biostatistics, McMaster University, Health Sciences Building (HSB), 1280 Main Street West, Hamilton, Ontario L8N 3Z5, Canada.
| | - Ashley J Bonner
- Health Research Methods (HRM), Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8N 3Z5, Canada
| | - Arnav Agarwal
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario L8N 3Z5, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario L8N 3Z5, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shelly-Anne Li
- Health Research Methods (HRM), Department of Clinical Epidemiology and Biostatistics, McMaster University, Health Sciences Building (HSB), 1280 Main Street West, Hamilton, Ontario L8N 3Z5, Canada
| | - Abishek Hariharan
- Life Sciences IV, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada
| | - Zain Izhar
- Life Sciences IV, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada
| | - Neera Bhatnagar
- Health Sciences Library, McMaster University, Hamilton, Ontario L8N 3Z5, Canada
| | - Carolina Alba
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario L8N 3Z5, Canada; Division of Cardiology and Heart Transplantation, University Health Network, 585 University Avenue, Toronto, Ontario, Canada
| | - Elie A Akl
- Clinical Epidemiology Unit, American University of Beirut, Lebanon; Center for Systematic Reviews in Health Policy and Systems Research (SPARK), American University of Beirut, Lebanon
| | - Yutong Fei
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Health Sciences Building (HSB), 1280 Main Street West, Hamilton, Ontario L8N 3Z5, Canada; Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario L8N 3Z5, Canada
| | - Joseph Beyene
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Michael DeGroote Centre for Learning & Discovery, Room 3208, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada; John D. Cameron Endowed Chair in Genetic Epidemiology, McMaster University, Michael DeGroote Centre for Learning & Discovery, Room 3208, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada; Population Genomics Program, McMaster University, Michael DeGroote Centre for Learning & Discovery, Room 3208, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada
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Ouellet J, Bailey D, Samson MÈ. Current Opinions on Stress-Related Mucosal Disease Prevention in Canadian Pediatric Intensive Care Units. J Pediatr Pharmacol Ther 2015; 20:299-308. [PMID: 26380570 DOI: 10.5863/1551-6776-20.4.299] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To describe current opinions about stress-related mucosal disease (SRMD) prevention in Canadian pediatric intensive care units (PICUs). METHODS A 22-question survey covering several aspects of SRMD was sent to all identified PICU attendings in Canada. RESULTS Sixty-eight percent of identified attendings completed the questionnaire. Thirty-eight percent were based in Quebec, 31% in Alberta, and 31% from other provinces. Most attendings (78%) had worked in a PICU for 6 years or more. When asked about risk factors for prescribing SRMD prevention drugs (more than 1 answer was accepted), the most popular answers were prior history of gastric ulceration/bleeding (33 respondents), coagulopathy (28 respondents), and major neurologic insult (18 respondents). Almost half of the attendings (48%) mentioned that they prescribe SRMD prophylaxis directly upon PICU admission to more than 25% of their patients. Forty-nine percent of respondents subjectively estimated that clinically significant upper gastrointestinal bleeding (UGIB; defined as UGIB associated with either hypotension, transfusion within 24 hours of the event, or death) occurred in less than 1% of their patients. Fifty-seven respondents (93%) used ranitidine as first-line therapy (average dose: 4.1 mg/kg/day, mainly intravenously). As second-line therapy, 32 attendings (52%) used pantoprazole and 13 (21%) used omeprazole. CONCLUSIONS Despite the paucity of guidelines on SRMD prevention and the low reported incidence of clinically significant UGIB, SRMD prevention is frequently used in Canadian PICUs. Ranitidine is the first-line drug used by most attendings.
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Affiliation(s)
- Jérôme Ouellet
- Pediatrics Residency Program, Department of Pediatrics, CME-CHU de Québec, Laval University, Québec, Canada
| | - Dennis Bailey
- Pediatric Critical Care Unit, Department of Pediatrics, CME-CHU de Québec, Laval University, Québec, Canada
| | - Marie-Ève Samson
- Pediatric Critical Care Unit, Department of Pediatrics, CME-CHU de Québec, Laval University, Québec, Canada
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Prevalence and outcome of gastrointestinal bleeding and use of acid suppressants in acutely ill adult intensive care patients. Intensive Care Med 2015; 41:833-45. [PMID: 25860444 DOI: 10.1007/s00134-015-3725-1] [Citation(s) in RCA: 176] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 02/27/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE To describe the prevalence of, risk factors for, and prognostic importance of gastrointestinal (GI) bleeding and use of acid suppressants in acutely ill adult intensive care patients. METHODS We included adults without GI bleeding who were acutely admitted to the intensive care unit (ICU) during a 7-day period. The primary outcome was clinically important GI bleeding in ICU, and the analyses included estimations of baseline risk factors and potential associations with 90-day mortality. RESULTS A total of 1,034 patients in 97 ICUs in 11 countries were included. Clinically important GI bleeding occurred in 2.6 % (95 % confidence interval 1.6-3.6 %) of patients. The following variables at ICU admission were independently associated with clinically important GI bleeding: three or more co-existing diseases (odds ratio 8.9, 2.7-28.8), co-existing liver disease (7.6, 3.3-17.6), use of renal replacement therapy (6.9, 2.7-17.5), co-existing coagulopathy (5.2, 2.3-11.8), acute coagulopathy (4.2, 1.7-10.2), use of acid suppressants (3.6, 1.3-10.2) and higher organ failure score (1.4, 1.2-1.5). In ICU, 73 % (71-76 %) of patients received acid suppressants; most received proton pump inhibitors. In patients with clinically important GI bleeding, crude and adjusted odds for mortality were 3.7 (1.7-8.0) and 1.7 (0.7-4.3), respectively. CONCLUSIONS In ICU patients clinically important GI bleeding is rare, and acid suppressants are frequently used. Co-existing diseases, liver failure, coagulopathy and organ failures are the main risk factors for GI bleeding. Clinically important GI bleeding was not associated with increased adjusted 90-day mortality, which largely can be explained by severity of comorbidity, other organ failures and age.
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Kimball EJ, Kim W, Cheatham ML, Malbrain MLNG. Clinical awareness of intra-abdominal hypertension and abdominal compartment syndrome in 2007. Acta Clin Belg 2014; 62 Suppl 1:66-73. [PMID: 24881702 DOI: 10.1179/acb.2007.62.s1.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION There has been an exponentially increasing interest in intra-abdominal hypertension (IAH). The aim of this review is to evaluate the evolution in clinical awareness of this syndrome. METHODS A PubMed (U.S. National Library of Medicine) search and a ScienceDirect (Elsevier B.V.) search of recent literature were performed in order to assess clinical awareness of IAH and abdominal compartment syndrome (ACS). RESULTS In total, 489 articles and 8 clinical surveys have been identified. The results of the landmark papers and the surveys will be briefly discussed in this review. CONCLUSION Clinical awareness of ACS is steadily increasing. It is time to pay attention to ACS, but further, it is time to move forward with therapeutic bundles in a multi-centered, outcome trial on IAH/ACS therapy in order to elevate IAH/ACS management to an international standard of care.
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Lee TH, Hung FM, Yang LH. Comparison of the efficacy of esomeprazole and famotidine against stress ulcers in a neurosurgical intensive care unit. ADVANCES IN DIGESTIVE MEDICINE 2014. [DOI: 10.1016/j.aidm.2013.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Boudoulas KD, Bowen T, Pederzolli A, Pfahl K, Pompili VJ, Mazzaferri EL. Duration of intra-aortic balloon pump use and related complications. ACTA ACUST UNITED AC 2014; 16:74-7. [DOI: 10.3109/17482941.2014.889311] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Mejia A, Kraft WK. Acid peptic diseases: pharmacological approach to treatment. Expert Rev Clin Pharmacol 2014; 2:295-314. [PMID: 21822447 DOI: 10.1586/ecp.09.8] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Acid peptic disorders are the result of distinctive, but overlapping pathogenic mechanisms leading to either excessive acid secretion or diminished mucosal defense. They are common entities present in daily clinical practice that, owing to their chronicity, represent a significant cost to healthcare. Key elements in the success of controlling these entities have been the development of potent and safe drugs based on physiological targets. The histamine-2 receptor antagonists revolutionized the treatment of acid peptic disorders owing to their safety and efficacy profile. The proton-pump inhibitors (PPIs) represent a further therapeutic advance due to more potent inhibition of acid secretion. Ample data from clinical trials and observational experience have confirmed the utility of these agents in the treatment of acid peptic diseases, with differential efficacy and safety characteristics between and within drug classes. Paradigms in their speed and duration of action have underscored the need for new chemical entities that, from a single dose, would provide reliable duration of acid control, particularly at night. Moreover, PPIs reduce, but do not eliminate, the risk of ulcers in patients taking NSAIDs, reflecting untargeted physiopathologic pathways and a breach in the ability to sustain an intragastric pH of more than 4. This review provides an assessment of the current understanding of the physiology of acid production, a discussion of medications targeting gastric acid production and a review of efficacy in specific acid peptic diseases, as well as current challenges and future directions in the treatment of acid-mediated diseases.
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Affiliation(s)
- Alex Mejia
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, 1170 Main Building, 132 South 10th Street, Philadelphia, PA 19107-5244, USA, Tel.: +1 203 243 7501
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Madani S, Kauffman R, Simpson P, Lehr VT, Lai ML, Sarniak A, Tolia V. Pharmacokinetics and pharmacodynamics of famotidine and ranitidine in critically ill children. J Clin Pharmacol 2013; 54:201-5. [PMID: 24258773 DOI: 10.1002/jcph.219] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 10/24/2013] [Indexed: 12/27/2022]
Abstract
To characterize and compare acid suppression (pharmacodynamics) and pharmacokinetics of IV famotidine and ranitidine in critically ill children at risk for stress gastritis. Single-blind, randomized study in PICU patients 6 months to 18 years requiring mechanical ventilation with continuous gastric pH monitoring, randomized to IV famotidine 12 mg/m(2) or ranitidine 60 mg/m(2) when gastric pH < 4.0 >1 hour with serial blood sampling following first dose. Twenty-four children randomized to either famotidine (n = 12) or ranitidine (n = 12). Sixteen out of twenty-four completed both PK and PD study arms (7/12 famotidine; 4.7 ± 3.4 years; 9/12 ranitidine; 6.6 ± 4.7 years; p = 0.38). Time to gastric pH 4.0 and total time pH above 4.0 similar with no difference in pH at 6 and 12 hours (p > 0.2). No difference between drugs in clearance, volume of distribution and half-life (p > 0.05). Ratio of AUC pH to AUC drug concentration 0-12 hours after first dose was significantly greater for famotidine (0.06849 ± 0.01460 SD) than ranitidine (0.02453 ± 0.01448; p < 0.001) demonstrating greater potency of famotidine. pH lowering efficacy of both drugs is similar. Greater potency of famotidine may offer clinical advantage due to lower drug exposure and less frequent dosing to achieve same pH lowering effect.
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Affiliation(s)
- Shailender Madani
- Division of Gastroenterology, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, USA
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KRAG M, PERNER A, WETTERSLEV J, MØLLER MH. Stress ulcer prophylaxis in the intensive care unit: is it indicated? A topical systematic review. Acta Anaesthesiol Scand 2013; 57:835-47. [PMID: 23495933 DOI: 10.1111/aas.12099] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2013] [Indexed: 12/18/2022]
Abstract
UNLABELLED Stress ulcer prophylaxis (SUP) is regarded as standard of care in the intensive care unit (ICU). However, recent randomized, clinical trials (RCTs) and meta-analyses have questioned the rationale and level of evidence for this recommendation. The aim of the present systematic review was to evaluate if SUP in the critically ill patients is indicated. DATA SOURCES MEDLINE including MeSH, EMBASE, and the Cochrane Library. PARTICIPANTS patients in the ICU. INTERVENTIONS pharmacological and non-pharmacological SUP. STUDY APPRAISAL AND SYNTHESIS METHODS Risk of bias was assessed according to Grading of Recommendations Assessment, Development, and Evaluation, and risk of random errors in cumulative meta-analyses was assessed with trial sequential analysis. A total of 57 studies were included in the review. The literature on SUP in the ICU includes limited trial data and methodological weak studies. The reported incidence of gastrointestinal (GI) bleeding varies considerably. Data on the incidence and severity of GI bleeding in general ICUs in the developed world as of today are lacking. The best intervention for SUP is yet to be settled by balancing efficacy and harm. In essence, it is unresolved if intensive care patients benefit overall from SUP. The following clinically research questions are unanswered: (1) What is the incidence of GI bleeding, and which interventions are used for SUP in general ICUs today?; (2) Which criteria are used to prescribe SUP?; (3) What is the best SUP intervention?; (4) Do intensive care patients benefit from SUP with proton pump inhibitors as compared with other SUP interventions? Systematic reviews of possible interventions and well-powered observational studies and RCTs are needed.
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Affiliation(s)
- M. KRAG
- Department of Intensive Care; Copenhagen University Hospital; Rigshospitalet; Denmark
| | - A. PERNER
- Department of Intensive Care; Copenhagen University Hospital; Rigshospitalet; Denmark
| | - J. WETTERSLEV
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen University Hospital; Rigshospitalet; Denmark
| | - M. H. MØLLER
- Department of Intensive Care; Copenhagen University Hospital; Rigshospitalet; Denmark
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Rolle des Gastrointestinaltrakts im Rahmen kardiochirurgischer Eingriffe. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2013. [DOI: 10.1007/s00398-013-1011-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Osman D, Djibré M, Da Silva D, Goulenok C. Management by the intensivist of gastrointestinal bleeding in adults and children. Ann Intensive Care 2012; 2:46. [PMID: 23140348 PMCID: PMC3526517 DOI: 10.1186/2110-5820-2-46] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 10/05/2012] [Indexed: 12/12/2022] Open
Abstract
Intensivists are regularly confronted with the question of gastrointestinal bleeding. To date, the latest international recommendations regarding prevention and treatment for gastrointestinal bleeding lack a specific approach to the critically ill patients. We present recommendations for management by the intensivist of gastrointestinal bleeding in adults and children, developed with the GRADE system by an experts group of the French-Language Society of Intensive Care (Société de Réanimation de Langue Française (SRLF), with the participation of the French Language Group of Paediatric Intensive Care and Emergencies (GFRUP), the French Society of Emergency Medicine (SFMU), the French Society of Gastroenterology (SNFGE), and the French Society of Digestive Endoscopy (SFED). The recommendations cover five fields of application: management of gastrointestinal bleeding before endoscopic diagnosis, treatment of upper gastrointestinal bleeding unrelated to portal hypertension, treatment of upper gastrointestinal bleeding related to portal hypertension, management of presumed lower gastrointestinal bleeding, and prevention of upper gastrointestinal bleeding in intensive care.
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Affiliation(s)
- David Osman
- AP-HP, Hôpitaux universitaires Paris-Sud, Hôpital de Bicêtre, Service de réanimation médicale, Le Kremlin-Bicêtre, F-94270, France.
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Chanpura T, Yende S. Weighing risks and benefits of stress ulcer prophylaxis in critically ill patients. Crit Care 2012; 16:322. [PMID: 23101485 PMCID: PMC3682308 DOI: 10.1186/cc11819] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Expanded abstract
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Liu BL, Li B, Zhang X, Fei Z, Hu SJ, Lin W, Gao DK, Zhang L. A randomized controlled study comparing omeprazole and cimetidine for the prophylaxis of stress-related upper gastrointestinal bleeding in patients with intracerebral hemorrhage. J Neurosurg 2012; 118:115-20. [PMID: 23061387 DOI: 10.3171/2012.9.jns12170] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Patients with intracerebral hemorrhage (ICH) are at high risk for severe stress-related upper gastrointestinal (UGI) bleeding, which is predictive of higher mortality. The aim of this study was to evaluate the effectiveness of omeprazole and cimetidine compared with a placebo in the prevention and management of stress-related UGI bleeding in patients with ICH. METHODS In a single-center, randomized, placebo-controlled study, 184 surgically treated patients with CT-proven ICH within 72 hours of ictus and negative results for gastric occult blood testing were included. Of these patients, 165 who were qualified upon further evaluation were randomized into 3 groups: 58 patients received 40 mg intravenous omeprazole every 12 hours, 54 patients received 300 mg intravenous cimetidine every 6 hours, and 53 patients received a placebo. Patients whose gastric occult blood tests were positive at admission (n = 70) and during/after the prophylaxis procedure (n = 48) were treated with high-dose omeprazole at 80 mg bolus plus 8 mg/hr infusion for 3 days, followed by 40 mg intravenous omeprazole every 12 hours for 7 days. RESULTS Of the 165 assessable patients, stress-related UGI bleeding occurred in 9 (15.5%) in the omeprazole group compared with 15 patients (27.8%) in the cimetidine group and 24 patients (45.3%) in the placebo group (p = 0.003). The occurrence of UGI bleeding was significantly related to death (p = 0.022). Nosocomial pneumonia occurred in 14 patients (24.1%) receiving omeprazole, 12 (22.2%) receiving cimetidine, and 8 (15.1%) receiving placebo (p > 0.05). In patients with UGI bleeding in which high-dose omeprazole was initiated, UGI bleeding arrested within the first 3 days in 103 patients (87.3%). CONCLUSIONS Omeprazole significantly reduced the morbidity of stress-related UGI bleeding in patients with ICH due to its effective prophylactic effect without increasing the risk of nosocomial pneumonia, but it did not reduce the 1-month mortality or ICU stay. Further evaluation of high-dose omeprazole as the drug of choice for patients presenting with UGI bleeding is warranted. Clinical trial registration no.: ChiCTR-TRC-12001871, registered at the Chinese clinical trial registry (http://www.chictr.org/en/proj/show.aspx?proj=2384).
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Affiliation(s)
- Bo-lin Liu
- Department of Neurosurgery, Xijing Institute of Clinical Neuroscience, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi Province, People's Republic of China
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Issa IA, Soubra O, Nakkash H, Soubra L. Variables associated with stress ulcer prophylaxis misuse: a retrospective analysis. Dig Dis Sci 2012; 57:2633-41. [PMID: 22427129 DOI: 10.1007/s10620-012-2104-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Accepted: 02/21/2012] [Indexed: 01/12/2023]
Abstract
BACKGROUND Stress ulcer prophylaxis (SUP) is commonly used in hospitals. Although its indications are better delineated for intensive care unit (ICU) patients, its use in non-ICU settings is somewhat arbitrary and based on judgment. OBJECTIVE We attempted to assess the extent of SUP overuse in our hospital. We also carefully collected and analyzed several variables to detect associations governing this flawed behavior and its financial burden on the hospital's budget. MATERIALS AND METHODS We retrospectively analyzed charts of patients admitted to the medical floor of a tertiary referral university hospital over a 1 year period. All adult patients admitted to the medical ward who received at least one dose of SUP were included and reviewed for a multitude of variables in addition to the appropriateness of acid suppression therapy (AST). RESULTS We included 320 charts and found that 92% of patients admitted during that period were not eligible for SUP. The total inappropriateness of SUP was noted to be 58% (p = 0.015). Increasing age and male gender were found to be significant variables in AST misuse (p = 0.045 and p = 0.010), much like duration of hospital stay (p = 0.008). Comorbidities was also found to be a defining variable for AST overuse (odds ratio [OR] = 3.27). Patients with two or more minor risk factors were also subjected more to SUP inappropriately (OR = 3.53), in addition to patients of certain specialties (Neurology, Infectious Diseases, etc.). Our calculated financial burden was more than $23,000 per year for the medical floor. CONCLUSION This retrospective study confirmed the growing suspicion that SUP misuse is evident on the medical floors. We also delineated several factors and variables associated with and affecting SUP overuse.
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Affiliation(s)
- Iyad A Issa
- Department of Internal Medicine, Division of Gastroenterology, Rafik Hariri University Hospital, Specialty Clinics Center, 4B Hamra, Beirut 2034-7304, Lebanon.
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Mutlu GM, Mutlu EA, Factor P. Prevention and Treatment of Gastrointestinal Complications in Patients on Mechanical Ventilation. ACTA ACUST UNITED AC 2012; 2:395-411. [PMID: 14719992 DOI: 10.1007/bf03256667] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
There exists a complex, dynamic interaction between mechanical ventilation and the splanchnic vasculature that contributes to a myriad of gastrointestinal tract complications that arise during critical illness. Positive pressure-induced splanchnic hypoperfusion appears to play a pivotal role in the pathogenesis of these complications, the most prevalent of which are stress-related mucosal damage, gastrointestinal hypomotility and diarrhea. Furthermore, characteristics of the splanchnic vasculature make the gastrointestinal tract vulnerable to adverse effects related to positive pressure ventilation. While most of these complications seen in mechanically ventilated patients are reflections of altered gastrointestinal physiology, some may be attributed to medical interventions instituted to treat critical illness. Since maintenance of normal hemodynamics cannot always be achieved, pharmacologic prophylactic therapy has become a mainstay in the prevention of gastrointestinal complications in the intensive care unit. Improved understanding of the systemic effects of mechanical ventilation and greater application of lung-protective ventilatory strategies may potentially minimize positive pressure-induced reductions in splanchnic perfusion, systemic cytokine release and, consequently, reduce the incidence of gastrointestinal complications associated with mechanical ventilation. Herein, we discuss the pathophysiology of gastrointestinal complications associated with mechanical ventilation, summarize the most prevalent complications and focus on preventive strategies and available treatment options for these complications. The most common causes of gastrointestinal hemorrhage in mechanically ventilated patients are bleeding from stress-related mucosal damage and erosive esophagitis. In general, histamine H(2) receptor antagonists and proton pump inhibitors prevent stress-related mucosal disease by raising the gastric fluid pH. Proton pump inhibitors tend to provide more consistent pH control than histamine H(2) receptor antagonists. There is no consensus on the drug of choice for stress ulcer prophylaxis with several meta-analyses providing conflicting results on the superiority of any medication. Prevention of erosive esophagitis include careful use of nasogastric tubes and institution of strategies that improve gastric emptying. Many mechanically ventilated patients have gastrointestinal hypomotility and diarrhea. Treatment options for gastrointestinal motility are limited, thus, preventive measures such as correction of electrolyte abnormalities and avoidance of medications that impair gastrointestinal motility are crucial. Treatment of diarrhea depends on the underlying cause. When associated with Clostridium difficile infection antibacterial therapy should be discontinued, if possible, and treatment with oral metronidazole should be initiated.More studies are warranted to better understand the systemic effects of mechanical ventilation on the gastrointestinal tract and to investigate the impact of lung protective ventilatory strategies on gastrointestinal complications.
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Affiliation(s)
- Gökhan M Mutlu
- Division of Pulmonary and Critical Care Medicine, Evanston Northwestern Healthcare, Evanston Illinois and Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
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Gupta D, Agarwal R, Aggarwal AN, Singh N, Mishra N, Khilnani GC, Samaria JK, Gaur SN, Jindal SK. Guidelines for diagnosis and management of community- and hospital-acquired pneumonia in adults: Joint ICS/NCCP(I) recommendations. Lung India 2012; 29:S27-62. [PMID: 23019384 PMCID: PMC3458782 DOI: 10.4103/0970-2113.99248] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Dheeraj Gupta
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Navneet Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Narayan Mishra
- Department of Pulmonary Medicine, Indian Chest Society, India
| | - G. C. Khilnani
- Department of Pulmonary Medicine, National College of Chest Physicians, India
| | - J. K. Samaria
- Department of Pulmonary Medicine, Indian Chest Society, India
| | - S. N. Gaur
- Department of Pulmonary Medicine, National College of Chest Physicians, India
| | - S. K. Jindal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - for the Pneumonia Guidelines Working Group
- Pneumonia Guidelines Working Group Collaborators (43) A. K. Janmeja, Chandigarh; Abhishek Goyal, Chandigarh; Aditya Jindal, Chandigarh; Ajay Handa, Bangalore; Aloke G. Ghoshal, Kolkata; Ashish Bhalla, Chandigarh; Bharat Gopal, Delhi; D. Behera, Delhi; D. Dadhwal, Chandigarh; D. J. Christopher, Vellore; Deepak Talwar, Noida; Dhruva Chaudhry, Rohtak; Dipesh Maskey, Chandigarh; George D’Souza, Bangalore; Honey Sawhney, Chandigarh; Inderpal Singh, Chandigarh; Jai Kishan, Chandigarh; K. B. Gupta, Rohtak; Mandeep Garg, Chandigarh; Navneet Sharma, Chandigarh; Nirmal K. Jain, Jaipur; Nusrat Shafiq, Chandigarh; P. Sarat, Chandigarh; Pranab Baruwa, Guwahati; R. S. Bedi, Patiala; Rajendra Prasad, Etawa; Randeep Guleria, Delhi; S. K. Chhabra, Delhi; S. K. Sharma, Delhi; Sabir Mohammed, Bikaner; Sahajal Dhooria, Chandigarh; Samir Malhotra, Chandigarh; Sanjay Jain, Chandigarh; Subhash Varma, Chandigarh; Sunil Sharma, Shimla; Surender Kashyap, Karnal; Surya Kant, Lucknow; U. P. S. Sidhu, Ludhiana; V. Nagarjun Mataru, Chandigarh; Vikas Gautam, Chandigarh; Vikram K. Jain, Jaipur; Vishal Chopra, Patiala; Vishwanath Gella, Chandigarh
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Guillaume A, Seres DS. Safety of Enteral Feeding in Patients With Open Abdomen, Upper Gastrointestinal Bleed, and Perforation Peritonitis. Nutr Clin Pract 2012; 27:513-20. [DOI: 10.1177/0884533612450919] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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The association between body mass index, processes of care, and outcomes from mechanical ventilation: a prospective cohort study. Crit Care Med 2012; 40:1456-63. [PMID: 22430246 DOI: 10.1097/ccm.0b013e31823e9a80] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the association between excess weight and processes of care and outcomes for critically ill adults. DESIGN Prospective cohort study. SETTING Three medical intensive care units at two hospitals. PATIENTS Five hundred eighty mechanically ventilated adult patients admitted between February 1, 2006 and January 31, 2008. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After adjusting weight based on the recorded fluid balance before enrollment, 21.9% of subjects were categorized into different body mass index categories than without this adjustment. We used a competing risk analysis with events of interest considered death during hospitalization and successful liberation from mechanical ventilation. We found no statistically significant difference between body mass index categories (<25 kg/m² vs. 25 to <30 kg/m² vs. ≥30 kg/m²) in the competing risks analyses when the results were unadjusted or adjusted for severity of illness and comorbidities. When the analyses were adjusted for the use of continuous infusions of opioids and/or sedatives and ventilator parameters (tidal volume per ideal body weight, positive end-expiratory pressure, and airway pressure), subjects with an overweight fluid-balance-adjusted body mass index had significantly lower hazard ratios for dying while hospitalized (adjusted hazard ratio 0.68 [95% confidence interval 0.47-0.99], p=.044), and those with an obese fluid-adjusted body mass index had significantly higher hazard ratios for successful extubation (adjusted hazard ratio 1.53 [95% confidence interval 1.14-2.06], p=.005). An analysis of longer-term mortality found lower adjusted hazard ratios for subjects with overweight (adjusted hazard ratio 0.74 [95% confidence interval 0.56-0.96]) and obese (adjusted hazard ratio 0.74 [95% confidence interval 0.59-0.94]) fluid-balance-adjusted body mass indices. CONCLUSIONS Processes of provided care may affect the observed association between excess weight and outcomes for critically ill adults and should be considered when making inferences about observed results. It is unknown if disparities in processes of care are due to clinically justified reasons for variation, bias against heavier patients, or other reasons.
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Prise en charge par le réanimateur des hémorragies digestives de l’adulte et de l’enfant. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-012-0489-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Umberto Meduri G, Bell W, Sinclair S, Annane D. Pathophysiology of acute respiratory distress syndrome. Glucocorticoid receptor-mediated regulation of inflammation and response to prolonged glucocorticoid treatment. Presse Med 2011; 40:e543-60. [PMID: 22088618 PMCID: PMC9905212 DOI: 10.1016/j.lpm.2011.04.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 04/29/2011] [Indexed: 11/25/2022] Open
Abstract
Based on molecular mechanisms and physiologic data, a strong association has been established between dysregulated systemic inflammation and progression of ARDS. In ARDS patients, glucocorticoid receptor-mediated down-regulation of systemic inflammation is essential to restore homeostasis, decrease morbidity and improve survival and can be significantly enhanced with prolonged low-to-moderate dose glucocorticoid treatment. A large body of evidence supports a strong association between prolonged glucocorticoid treatment-induced down-regulation of the inflammatory response and improvement in pulmonary and extrapulmonary physiology. The balance of the available data from controlled trials provides consistent strong level of evidence (grade 1B) for improving patient-centered outcomes. The sizable increase in mechanical ventilation-free days (weighted mean difference, 6.58 days; 95% CI, 2.93 -10.23; P<0.001) and ICU-free days (weighted mean difference, 7.02 days; 95% CI, 3.20-10.85; P<0.001) by day 28 is superior to any investigated intervention in ARDS. The largest meta-analysis on the subject concluded that treatment was associated with a significant risk reduction (RR=0.62, 95% CI: 0.43-0.91; P=0.01) in mortality and that the in-hospital number needed to treat to save one life was 4 (95% CI 2.4-10). The balance of the available data, however, originates from small controlled trials with a moderate degree of heterogeneity and provides weak evidence (grade 2B) for a survival benefit. Treatment decisions involve a tradeoff between benefits and risks, as well as costs. This low cost highly effective therapy is familiar to every physician and has a low risk profile when secondary prevention measures are implemented.
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Affiliation(s)
- Gianfranco Umberto Meduri
- University of Tennessee Health Science Center and Memphis Veterans Affairs Medical Center, Critical Care and Sleep Medicine, Division of Pulmonary, Departments of Medicine, Memphis, 38104 TN, United States.
| | - William Bell
- University of Tennessee Health Science Center and Memphis Veterans Affairs Medical Center, Critical Care and Sleep Medicine, Division of Pulmonary, Departments of Medicine, Memphis, 38104 TN, United States
| | - Scott Sinclair
- University of Tennessee Health Science Center and Memphis Veterans Affairs Medical Center, Critical Care and Sleep Medicine, Division of Pulmonary, Departments of Medicine, Memphis, 38104 TN, United States
| | - Djillali Annane
- Université de Versailles SQY (UniverSud Paris), 92380 Garches, France
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Nseir S, Zerimech F, Fournier C, Lubret R, Ramon P, Durocher A, Balduyck M. Continuous Control of Tracheal Cuff Pressure and Microaspiration of Gastric Contents in Critically Ill Patients. Am J Respir Crit Care Med 2011; 184:1041-7. [DOI: 10.1164/rccm.201104-0630oc] [Citation(s) in RCA: 150] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Proton pump inhibitor prophylaxis increases the risk of nosocomial pneumonia in patients with an intracerebral hemorrhagic stroke. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 111:435-9. [PMID: 21725797 DOI: 10.1007/978-3-7091-0693-8_75] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
BACKGROUND Stress-related mucosal damage is an erosive process of the gastric lining resulting from abnormally high physiologic demands. To avoid the morbidity and mortality associated with significant bleeding from the damage, prophylaxis with an acid suppression medication is given. This is especially common in stroke victims. Recent studies have suggested a link between acid suppression therapy and nosocomial pneumonia, specifically implicating proton pump inhibitors (PPI), a potent acid suppression medication, as the culprit. In this retrospective study, we reviewed the medical records of admitted intracerebral hemorrhage (ICH) patients and determined if there is a link between PPI prophylaxis and nosocomial pneumonia in our ICH population. MATERIALS AND METHODS Medical records of 200 ICH patients admitted to the First Affiliated Hospital of Chongqing Medical University were reviewed from January 1, 2008 to October 31, 2009. PPIs were the only accepted form of acid suppression therapy. In all, 95 patients were given PPI prophylaxis, whereas 105 patients did not receive any form of acid suppression. RESULTS The unadjusted incidence rate of pneumonia in the PPI prophylactic group was 23.2%, and 10.5% in patients not having received prophylaxis. Additionally, patients treated with PPI prophylaxis were more likely to be critically ill, defined by an increase in conscious disturbance and dependency on mechanical ventilation and/or a nasogastric tube. CONCLUSION The use of a PPI as a prophylactic treatment against stress-related mucosal damage was associated with a higher occurrence of nosocomial pneumonia in our ICH population. This study suggests the need for further research investigating the use of PPI prophylaxis in ICH patients and the possibility of using alternate acid suppression therapeutic modalities.
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Goodwin CM, Hoffman JA. Deep Vein Thrombosis and Stress Ulcer Prophylaxis in the Intensive Care Unit. J Pharm Pract 2011; 24:78-88. [DOI: 10.1177/0897190010393851] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Deep vein thrombosis (DVT) and stress gastric ulcers can be serious complications in patients admitted to the intensive care unit. This review discusses the risk factors associated with the development of DVT and stress-related mucosal disease (SRMD), evaluates the available literature on current options for DVT and stress ulcer prophylaxis, and examines the associated adverse effects and optimal duration of therapy.
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Affiliation(s)
- Corey M. Goodwin
- Department of Pharmacy, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Jason A. Hoffman
- Department of Pharmacy, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
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Herzig SJ, Vaughn BP, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for nosocomial gastrointestinal tract bleeding. ACTA ACUST UNITED AC 2011; 171:991-7. [PMID: 21321285 DOI: 10.1001/archinternmed.2011.14] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Acid-suppressive medications are increasingly prescribed for noncritically ill hospitalized patients, although the incidence of nosocomial gastrointestinal (GI) tract bleeding (GI bleeding) and magnitude of potential benefit from this practice are unknown. We aimed to define the incidence of nosocomial GI bleeding outside of the intensive care unit and examine the association between acid-suppressive medication use and this complication. METHODS We conducted a pharmacoepidemiologic cohort study of patients admitted to an academic medical center from 2004 through 2007, at least 18 years of age, and hospitalized for 3 or more days. Admissions with a primary diagnosis of GI bleeding were excluded. Acid-suppressive medication use was defined as any order for a proton pump inhibitor or histamine-2-receptor antagonist. The main outcome measure was nosocomial GI bleeding. A propensity matched generalized estimating equation was used to control for confounders. RESULTS The final cohort included 78,394 admissions (median age, 56 years; 41% men). Acid-suppressive medication was ordered in 59% of admissions, and nosocomial GI bleeding occurred in 224 admissions (0.29%). After matching on the propensity score, the adjusted odds ratio for nosocomial GI bleeding in the group exposed to acid-suppressive medication relative to the unexposed group was 0.63 (95% confidence interval, 0.42-0.93). The number needed to treat to prevent 1 episode of nosocomial GI bleeding was 770. CONCLUSIONS Nosocomial GI bleeding outside of the intensive care unit was rare. Despite a protective effect of acid-suppressive medication, the number needed to treat to prevent 1 case of nosocomial GI bleeding was relatively high, supporting the recommendation against routine use of prophylactic acid-suppressive medication in noncritically ill hospitalized patients.
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Affiliation(s)
- Shoshana J Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Brookline, MA 02446, USA.
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Stress ulcer prophylaxis in the new millennium: A systematic review and meta-analysis. Crit Care Med 2010; 38:2222-8. [DOI: 10.1097/ccm.0b013e3181f17adf] [Citation(s) in RCA: 156] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Abstract
Clinical trials conducted in the latter part of the past millennium suggested that bleeding from gastric stress ulceration was an important cause of morbidity and mortality in intensive care unit (ICU) patients and that treatment with acid-suppressive therapy reduced the risk of clinically significant bleeding. Stress ulcer prophylaxis therefore became regarded as the standard of care in all ICU patients. However, more recent clinical trials have demonstrated that the risk of clinically significant bleeding is extremely low (about 1%) and not altered by the use of acid-suppressive therapy. Furthermore, a critical review of the “historical” clinical trials, as well as the data from experimental and more recent clinical trials, suggests that enteral feeding (gastric) is at least as effective as acid-suppressive therapy in the prevention of gastric stress ulceration and is the prophylactic measure of choice in most ICU patients.
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Pang SH, Graham DY. A clinical guide to using intravenous proton-pump inhibitors in reflux and peptic ulcers. Therap Adv Gastroenterol 2010; 3:11-22. [PMID: 21180586 PMCID: PMC3002568 DOI: 10.1177/1756283x09352095] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Intravenous (IV) proton-pump inhibitors (PPIs) are potent gastric acid suppressing agents, and their use is popular in clinical practice. Both IV and oral PPIs have similarly short half-lives, and their effects on acid secretion are similar, thus their dosing and dosage intervals appear to be interchangeable. The possible exception is when sustained high pHs are required to promote clot stabilization in bleeding peptic ulcers. Continuous infusion appears to be the only form of administration that reliably achieves these high target pHs. IV PPI is indicated in the treatment of high-risk peptic ulcers, complicated gastroesophageal reflux, stress-induced ulcer prophylaxis, Zollinger-Ellison syndrome, and whenever it is impossible or impractical to give oral therapy. The widespread use of PPIs has been controversial. IV PPIs have been linked to the development of nosocomial pneumonia in the intensive care setting and to spontaneous bacterial peritonitis in cirrhotic patients. This review discusses the use of IV PPI in different clinical scenarios, its controversies, and issues of appropriate use.
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Affiliation(s)
- Sandy H. Pang
- Institute of Digestive Disease, Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - David Y. Graham
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA,
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Abstract
PURPOSE OF REVIEW To discuss the risk factors and underlying illnesses that play a role in the pathophysiology of stress ulcer, and to evaluate the evidence pertaining to stress ulcer-related bleeding prophylaxis in critically ill patients. RECENT FINDINGS The use of stress ulcer prophylaxis is common in critical care medicine and is a major challenge to physicians in the ICU. The mechanism of stress ulcer is believed to be multifactorial, yet remains incompletely understood. The most widely used drugs for stress ulcer prophylaxis are intravenous histamine2-receptor antagonists. They raise gastric pH, but are associated with the development of tolerance, possible drug interactions, and neurologic manifestations. Sucralfate, which can be administered by the nasogastric route, can protect the gastric mucosa without raising pH, but may decrease absorption of concomitantly administered oral medications. Proton pump inhibitors are the most potent acid-inhibiting pharmacologic agents available. Proton pump inhibitors are at least as effective as histamine2-receptor antagonists, as a limited number of clinical trials have demonstrated. However, these trials were small, lacked an active comparator, varied in the number of risk factors, and used a different definition of clinically important bleeding than previously established. SUMMARY Routine prophylaxis against stress ulcers in the ICU is not well justified by current evidence. Patients at risk of stress ulcer-related bleeding are most likely to benefit from prophylaxis. Thus, healthcare professionals should continue to evaluate risk and assess the need for stress ulcer-related prophylaxis.
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Rauch S, Krueger K, Turan A, Roewer N, Sessler DI. Determining small intestinal transit time and pathomorphology in critically ill patients using video capsule technology. Intensive Care Med 2009; 35:1054-9. [DOI: 10.1007/s00134-009-1415-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Accepted: 12/11/2008] [Indexed: 12/22/2022]
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Abstract
Advances in the care of critically ill patients are dependent upon rigorous clinical research undertaken to characterize natural history and risk factors, and determine optimal approaches to the management of the diseases of the critically ill patient. The Canadian Critical Care Trials Group (CCCTG) was formed in 1989 to foster such research. It has grown to become a national, multidisciplinary organization with more than 100 members, and more than 3 dozen active research programs. Its members have been highly successful in obtaining funding for, completing, and publishing well-designed studies that have informed international practice in areas such as transfusion, stress ulcer prophylaxis, long term outcomes from acute respiratory distress syndrome, diagnosis and management of infection in the intensive care unit, and end-of-life care. In the process, the CCCTG has developed a highly effective culture of scientific mentoring, and has served as a model for investigator-led critical care research groups around the world. This review summarizes the history, activities, approaches, and challenges of the CCCTG, in the conviction that investigator-led groups such as ours represent the future of intensive care unit-based research.
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Bion J, Jaeschke R, Thompson BT, Levy M, Dellinger RP. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med 2008. [DOI: 10.1007/s00134-008-1090-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Comment on "Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008" by Dellinger et al. Intensive Care Med 2008; 34:1160-2; author reply 1163-4. [PMID: 18415078 PMCID: PMC2480487 DOI: 10.1007/s00134-008-1089-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2008] [Indexed: 01/04/2023]
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