Optimal therapy for stress gastritis

Prevalence of Gastric Ulceration in Horses with Enterolithiasis Compared with Horses with Simple Large Intestinal Obstruction

Enterolithiasis is a well-documented cause of colic in horses, especially in some geographic areas such as California and Florida. This retrospective case-control study aims at comparing the prevalence of gastric ulcers in horses affected by enterolithiasis to that in horses affected by other types of large intestinal obstruction. Two hundred and ninety-six horses were included in the study sample. Horses that had surgery for the removal of one or more enteroliths were included in the study as cases. Patients that had surgery for large intestinal simple obstructions other than enterolithiasis (large colon displacement, non-strangulating large colon torsion, and large and small colon impactions) were selected to match case horses for age, sex, and breed and included as controls. A total of 101/148 horses with enteroliths (68%) had gastric ulcers diagnosed during hospitalization, compared with 46/148 of matched controls (31%). There was a significant association between enterolithiasis and gastric ulceration (odds ratio 4.76, p < 0.0001), and a greater prevalence in Thoroughbreds as compared with other breeds (odds ratio 22.6, p < 0.0001). We concluded that enterolithiasis is significantly associated with gastric ulceration (p < 0.0001). The association is stronger in Thoroughbreds.

Interventions for preventing upper gastrointestinal bleeding in people admitted to intensive care units

BACKGROUND

Upper gastrointestinal (GI) bleeding due to stress ulcers contributes to increased morbidity and mortality in people admitted to intensive care units (ICUs). Stress ulceration refers to GI mucosal injury related to the stress of being critically ill. ICU patients with major bleeding as a result of stress ulceration might have mortality rates approaching 48.5% to 65%. However, the incidence of stress-induced GI bleeding in ICUs has decreased, and not all critically ill patients need prophylaxis. Stress ulcer prophylaxis can result in adverse events such as ventilator-associated pneumonia; therefore, it is necessary to evaluate strategies that safely decrease the incidence of GI bleeding.

OBJECTIVES

To assess the effect and risk-benefit profile of interventions for preventing upper GI bleeding in people admitted to ICUs.

SEARCH METHODS

We searched the following databases up to 23 August 2017, using relevant search terms: MEDLINE; Embase; the Cochrane Central Register of Controlled Trials; Latin American Caribbean Health Sciences Literature; and the Cochrane Upper Gastrointestinal and Pancreatic Disease Group Specialised Register, as published in the Cochrane Library (2017, Issue 8). We searched the reference lists of all included studies and those from relevant systematic reviews and meta-analyses to identify additional studies. We also searched the World Health Organization International Clinical Trials Registry Platform search portal and contacted individual researchers working in this field, as well as organisations and pharmaceutical companies, to identify unpublished and ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs with participants of any age and gender admitted to ICUs for longer than 48 hours. We excluded studies in which participants were admitted to ICUs primarily for the management of GI bleeding and studies that compared different doses, routes, and regimens of one drug in the same class because we were not interested in intraclass effects of drugs.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as recommended by Cochrane.

MAIN RESULTS

We identified 2292 unique records.We included 129 records reporting on 121 studies, including 12 ongoing studies and two studies awaiting classification.We judged the overall risk of bias of two studies as low. Selection bias was the most relevant risk of bias domain across the included studies, with 78 studies not clearly reporting the method used for random sequence generation. Reporting bias was the domain with least risk of bias, with 12 studies not reporting all outcomes that researchers intended to investigate.Any intervention versus placebo or no prophylaxisIn comparison with placebo, any intervention seems to have a beneficial effect on the occurrence of upper GI bleeding (risk ratio (RR) 0.47, 95% confidence interval (CI) 0.39 to 0.57; moderate certainty of evidence). The use of any intervention reduced the risk of upper GI bleeding by 10% (95% CI -12.0% to -7%). The effect estimate of any intervention versus placebo or no prophylaxis with respect to the occurrence of nosocomial pneumonia, all-cause mortality in the ICU, duration of ICU stay, duration of intubation (all with low certainty of evidence), the number of participants requiring blood transfusions (moderate certainty of evidence), and the units of blood transfused was consistent with benefits and harms. None of the included studies explicitly reported on serious adverse events.Individual interventions versus placebo or no prophylaxisIn comparison with placebo or no prophylaxis, antacids, H2 receptor antagonists, and sucralfate were effective in preventing upper GI bleeding in ICU patients. Researchers found that with H2 receptor antagonists compared with placebo or no prophylaxis, 11% less developed upper GI bleeding (95% CI -0.16 to -0.06; RR 0.50, 95% CI 0.36 to 0.70; 24 studies; 2149 participants; moderate certainty of evidence). Of ICU patients taking antacids versus placebo or no prophylaxis, 9% less developed upper GI bleeding (95% CI -0.17 to -0.00; RR 0.49, 95% CI 0.25 to 0.99; eight studies; 774 participants; low certainty of evidence). Among ICU patients taking sucralfate versus placebo or no prophylaxis, 5% less had upper GI bleeding (95% CI -0.10 to -0.01; RR 0.53, 95% CI 0.32 to 0.88; seven studies; 598 participants; moderate certainty of evidence). The remaining interventions including proton pump inhibitors did not show a significant effect in preventing upper GI bleeding in ICU patients when compared with placebo or no prophylaxis.Regarding the occurrence of nosocomial pneumonia, the effects of H2 receptor antagonists (RR 1.12, 95% CI 0.85 to 1.48; eight studies; 945 participants; low certainty of evidence) and of sucralfate (RR 1.33, 95% CI 0.86 to 2.04; four studies; 450 participants; low certainty of evidence) were consistent with benefits and harms when compared with placebo or no prophylaxis. None of the studies comparing antacids versus placebo or no prophylaxis provided data regarding nosocomial pneumonia.H2 receptor antagonists versus proton pump inhibitorsH2 receptor antagonists and proton pump inhibitors are most commonly used in practice to prevent upper GI bleeding in ICU patients. Proton pump inhibitors significantly more often prevented upper GI bleeding in ICU patients compared with H2 receptor antagonists (RR 2.90, 95% CI 1.83 to 4.58; 18 studies; 1636 participants; low certainty of evidence). When taking H2 receptor antagonists, 4.8% more patients might experience upper GI bleeding (95% CI 2.1% to 9%). Nosocomial pneumonia occurred in similar proportions of participants taking H2 receptor antagonists and participants taking proton pump inhibitors (RR 1.02, 95% CI 0.77 to 1.35; 10 studies; 1256 participants; low certainty of evidence).

AUTHORS' CONCLUSIONS

This review shows that antacids, sucralfate, and H2 receptor antagonists might be more effective in preventing upper GI bleeding in ICU patients compared with placebo or no prophylaxis. The effect estimates of any treatment versus no prophylaxis on nosocomial pneumonia were consistent with benefits and harms. Evidence of low certainty suggests that proton pump inhibitors might be more effective than H2 receptor antagonists. Therefore, patient-relevant benefits and especially harms of H2 receptor antagonists compared with proton pump inhibitors need to be assessed by larger, high-quality RCTs to confirm the results of previously conducted, smaller, and older studies.

Acid-Suppressive Therapy and Risk of Infections: Pros and Cons

This narrative review summarises the benefits, risks and appropriate use of acid-suppressing drugs (ASDs), proton pump inhibitors and histamine-2 receptor antagonists, advocating a rationale balanced and individualised approach aimed to minimise any serious adverse consequences. It focuses on current controversies on the potential of ASDs to contribute to infections-bacterial, parasitic, fungal, protozoan and viral, particularly in the elderly, comprehensively and critically discusses the growing body of observational literature linking ASD use to a variety of enteric, respiratory, skin and systemic infectious diseases and complications (Clostridium difficile diarrhoea, pneumonia, spontaneous bacterial peritonitis, septicaemia and other). The proposed pathogenic mechanisms of ASD-associated infections (related and unrelated to the inhibition of gastric acid secretion, alterations of the gut microbiome and immunity), and drug-drug interactions are also described. Both probiotics use and correcting vitamin D status may have a significant protective effect decreasing the incidence of ASD-associated infections, especially in the elderly. Despite the limitations of the existing data, the importance of individualised therapy and caution in long-term ASD use considering the balance of benefits and potential harms, factors that may predispose to and actions that may prevent/attenuate adverse effects is evident. A six-step practical algorithm for ASD therapy based on the best available evidence is presented.

Surgical Critical Care: Gastrointestinal Complications

Critical illness and injury affect the gastrointestinal tract almost uniformly. Complications include the sequelae of direct intestinal injury and repair, impaired motility, intra-abdominal hypertension, and ulceration, among others. Contemporary clinical practice has incorporated many advances in the prevention and treatment of gastrointestinal complications during critical illness. This article discusses the epidemiology, risk factors, means of diagnosis, treatment, and prevention of some of these compilations.

A Review of Stress Ulcer Prophylaxis

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.

A review of stress-related mucosal disease

OBJECTIVE

To review and summarize the human and veterinary literature regarding stress-related mucosal disease (SRMD) pathogenesis, patient risk factors, and therapeutic options for prophylaxis and treatment.

ETIOLOGY

SRMD is a common sequela of critical illness in human patients. Development of SRMD results from splanchnic hypoperfusion, reperfusion injury, and exposure of the gastric mucosa to acid, pepsin, and bile acids following breakdown of the gastric mucosal defense system. Human patients with the highest risk of stress ulceration include those with respiratory failure necessitating mechanical ventilation greater than 48 h or coagulopathy. Currently, little is known about the incidence and pathophysiology of SRMD in critically ill veterinary patients.

DIAGNOSIS

A presumptive diagnosis can be made in high-risk patient populations following detection of occult or gross blood in nasogastric tube aspirates, hematemesis, or melena. Definitive diagnosis is achieved via esophagogastroduodenoscopy. Lesions are localized to the acid-producing portions of the stomach, the fundus, and body.

THERAPY

Therapy is aimed at optimization of tissue perfusion and oxygenation. Pharmacologic interventions are instituted to increase intraluminal pH and augment natural gastric defenses. Histamine(2)-receptor antagonists, proton pump inhibitors, and sucralfate are the mainstays of therapy. In people, clinically significant bleeding may necessitate additional interventions (eg, packed red blood cell transfusions, endoscopic, or surgical hemostasis).

PROGNOSIS

Mortality is increased in people with clinically significant bleeding compared to those patients who do not bleed. Institution of prophylaxis is recommended in high-risk patients. However, no consensus exists regarding initiation of prophylaxis, preference of frontline drug class, or indication for discontinuation of therapy. The prognosis of veterinary patients with SRMD remains unknown at this time.

Prevention of gastrointestinal bleeding due to stress ulceration: a review of current literature

Our objective was to audit our current stress ulcer prophylaxis protocol (routine prescription of ranitidine and early enteral feeding) by identifying whether routine prescription of histamine-2 receptor antagonists or proton pump inhibitors as prophylaxis against stress-related mucosal disease and subsequent upper gastrointestinal bleeding is supported in the literature. We also aimed to ascertain what literature evidence supports the role of early enteral feeding as an adjunctive prophylactic therapy, as well as to search for burn-patient specific evidence, since burn patients are at high risk for developing this condition, with the aim of changing our practice. PubMed and Cochrane databases were searched for relevant articles, yielding seven randomised controlled trials comparing histamine-2 receptor antagonists and proton pump inhibitors in the prevention of upper gastrointestinal bleeding associated with stress-related mucosal disease and three separate meta-analyses. Despite level 1 clinical evidence, no significant difference in efficacy between histamine-2 receptor antagonists and proton pump inhibitor treatment groups was demonstrated. No significant difference was demonstrated in the incidence of nosocomial pneumonia between the two drugs given in this indication. However, enteral feeding was found to be safe and effective in preventing clinically significant upper gastrointestinal bleeding. Patients able to tolerate feeds demonstrated no additional benefit with concomitant pharmacological prophylactic therapy. Since all burn patients at the Royal Adelaide Hospital are fed from very early in their admission, the literature suggests that we, like our intensive care unit colleagues, should abolish our reliance on pharmacological prophylaxis, the routine prescription of which is not supported by the evidence.

Risk of fracture and pneumonia from acid suppressive drugs

A recently published systematic review and meta-analysis, incorporating all relevant studies on the association of acid suppressive medications and pneumonia identified up to August 2009, revealed that for every 200 patients, treated with acid suppressive medication, one will develop pneumonia. They showed the overall risk of pneumonia was higher among people using proton pump inhibitors (PPIs) [adjusted odds ratio (OR) = 1.27, 95% CI: 1.11-1.46, I² = 90.5%] and Histamine_-2 receptor antagonists (H₂RAs) (adjusted OR = 1.22, 95% CI: 1.09-1.36, I² = 0.0%). In the randomized controlled trials, use of H₂RAs was associated with an elevated risk of hospital-acquired pneumonia (relative risk 1.22, 95% CI: 1.01-1.48, I² = 30.6%). Another meta-analysis of 11 studies published between 1997 and 2011 found that PPIs, which reduce stomach acid production, were associated with increased risk of fracture. The pooled OR for fracture was 1.29 (95% CI: 1.18-1.41) with use of PPIs and 1.10 (95% CI: 0.99-1.23) with use of H₂RAs, when compared with non-use of the respective medications. Long-term use of PPIs increased the risk of any fracture (adjusted OR = 1.30, 95% CI: 1.15-1.48) and of hip fracture risk (adjusted OR = 1.34, 95% CI: 1.09-1.66), whereas long-term H₂RA use was not significantly associated with fracture risk. Clinicians should carefully consider when deciding to prescribe acid-suppressive drugs, especially for patients who are already at risk for pneumonia and fracture. Since it is unnecessary to achieve an achlorhydric state in order to resolve symptoms, we recommend using the only minimum effective dose of drug required to achieve the desired therapeutic goals.

Use of acid-suppressive drugs and risk of pneumonia: a systematic review and meta-analysis

BACKGROUND

Observational studies and randomized controlled trials have yielded inconsistent findings about the association between the use of acid-suppressive drugs and the risk of pneumonia. We performed a systematic review and meta-analysis to summarize this association.

METHODS

We searched three electronic databases (MEDLINE [PubMed], Embase and the Cochrane Library) from inception to Aug. 28, 2009. Two evaluators independently extracted data. Because of heterogeneity, we used random-effects meta-analysis to obtain pooled estimates of effect.

RESULTS

We identified 31 studies: five case-control studies, three cohort studies and 23 randomized controlled trials. A meta-analysis of the eight observational studies showed that the overall risk of pneumonia was higher among people using proton pump inhibitors (adjusted odds ratio [OR] 1.27, 95% confidence interval [CI] 1.11-1.46, I(2) 90.5%) and histamine(2) receptor antagonists (adjusted OR 1.22, 95% CI 1.09-1.36, I(2) 0.0%). In the randomized controlled trials, use of histamine(2) receptor antagonists was associated with an elevated risk of hospital-acquired pneumonia (relative risk 1.22, 95% CI 1.01-1.48, I(2) 30.6%).

INTERPRETATION

Use of a proton pump inhibitor or histamine(2) receptor antagonist may be associated with an increased risk of both community- and hospital-acquired pneumonia. Given these potential adverse effects, clinicians should use caution in prescribing acid-suppressive drugs for patients at risk.

Gastric alkalinization after major trauma

BACKGROUND

Gastric function in trauma patients is poorly understood. In animals, shock causes gastric luminal alkalinization and bile reflux. In trauma patients, studies of stress gastritis prophylaxis demonstrated with continuous gastric pH monitoring that the stomach became alkaline even without antisecretory therapy. Therefore, we hypothesized that trauma patients have an alkaline gastric environment that may be because of bile reflux.

METHODS

A prospective observational study at an urban Level I trauma center was performed. All major torso trauma patients (severe head injuries excluded) who met the criteria for standardized shock resuscitation were eligible for inclusion. A 12.5 Fr silastic pH probe (Sandhill Scientific) was placed in the stomach and the gastric pH continuously monitored for 7 days. Patients received no stress gastritis prophylaxis. Gastric samples were obtained each day and assayed for total bile acids and pH.

RESULTS

Twelve patients were entered into the study. Mean age was 31 years +/- 4 years, 67% men, 75% blunt mechanism of injury, and mean Injury Severity Score 28 +/- 3. Three patients (25%) developed multiple organ failure and four acquired ventilator-associated pneumonia. During the first day of continuous pH monitoring, 9 of 12 patients had a gastric pH >4 for the majority of the day with 7 patients having essentially no acid production. During subsequent days, gastric pH began to drop and by the 4th day the majority of each day was spent at a pH <4. Additionally, gastric pH of patients with ventilator-associated pneumonia or multiple organ failure tended to be more alkaline. Bile acid was present in the gastric fluid of all patients in varying amounts. However, there was no significant correlation between gastric pH and bile acid concentration.

CONCLUSIONS

Traumatic injury causes gastric luminal alkalinization that may be related, only in part, to bile acid reflux. Other alkalinizing factors remain to be elucidated.

Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths

OBJECTIVE

To identify patterns of errors contributing to inpatient trauma deaths.

METHODS

All inpatient trauma deaths at a high-volume level I trauma center from 1996 to 2004 inclusive were audited. Data were collected with daily trauma registry chart abstraction, weekly morbidity and mortality reports, hospital quality assurance reports, and annual trauma registry analyses of risk of death using TRISS and HARM methodology. Deaths that met criteria for low to medium probability of mortality or those with quality of care concerns were analyzed for errors and then subjected to 3-stage peer review at weekly departmental, monthly hospital, and annual regional forums. Patterns of errors were constructed from the compiled longitudinal data.

RESULTS

In 9 years, there were 44,401 trauma patient admissions and 2,594 deaths (5.8%), of which 601 met low to medium mortality risks. Sixty-four patients (0.14% admissions, 2.47% deaths) had recognized errors in care that contributed to their death. Important error patterns included: failure to successfully intubate, secure or protect an airway (16%), delayed operative or angiographic control of acute abdominal/pelvic hemorrhage (16%), delayed intervention for ongoing intrathoracic hemorrhage (9%), inadequate DVT or gastrointestinal prophylaxis (9%), lengthy initial operative procedures rather than damage control surgery in unstable patients (8%), over-resuscitation with fluids (5%), and complications of feeding tubes (5%). Resulting data-directed institutional and regional trauma system policy changes have demonstrably reduced the incidence of associated error-related deaths.

CONCLUSIONS

Preventable deaths will occur even in mature trauma systems. This review has identified error patterns that are likely common in all trauma systems, and for which policy interventions can be effectively targeted.

Ketamine-induced gastroprotection during endotoxemia: role of heme-oxygenase-1

Inducible nitric oxide synthase contributes to lipopolysacharide-induced gastric injury. In contrast, heme-oxygenase-1 has anti-inflammatory effects and is protective against oxidative tissue injury. Ketamine attenuates injury from lipopolysacharide and is associated with changes in oxidative stress proteins, but its effects on the stomach remain to be fully elucidated. We hypothesized that ketamine would diminish gastric injury from lipopolysacharide via down-regulation of nuclear factor-kappass, activator protein-1, and inducible nitric oxide synthase, as well as up-regulation of heme-oxygenase-1. Ketamine up-regulated heme-oxygenase-1 and attenuated lipopolysacharide-induced changes in gastric nuclear factor-kappass, activator protein-1, and inducible nitric oxide synthase. Ketamine negated LPS-induced gastric injury from acidified ethanol, an effect reversed by tin protoporphorin IX. Ketamine diminishes the susceptibility of gastric mucosa to damage from luminal irritants during endotoxemia, which is mediated in part by down-regulation of iNOS and up-regulation of HO-1.

Stress-related mucosal disease: risk factors and prophylactic therapy

BACKGROUND

The term stress-related mucosal disease (SRMD) represents a continuum of conditions ranging from stress-related injury (superficial mucosal damage) to stress ulcers (focal deep mucosal damage). Caused by mucosal ischemia, SRMD is most commonly seen in critically ill patients in the intensive care unit (ICU). Prophylaxis of stress ulcers may reduce major bleeding but has not yet been shown to improve survival.

OBJECTIVES

This article reviews currently available agents for the prophylaxis of SRMD and discusses their uses and potential adverse effects.

METHODS

Relevant articles in the English-language literature were identified through a MEDLINE search (1968-2003) using the key words stress-related mucosal disease, stress-related injury, ulcer, prophylaxis, intensive care unit, and upper gastrointestinal bleeding.

RESULTS

The most widely used drugs for stress-related injury are the intravenous histamine(2)-receptor antagonists. These drugs raise gastric pH but are associated with the development of tolerance and 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 the absorption of concomitantly administered oral medications. The prostaglandin misoprostol has not been shown to be of benefit in the prophylaxis of SRMD. Antacids lower the risk of gastrointestinal bleeding, but large volumes of antacids are required and treatment is labor intensive. Proton pump inhibitors (PPIs) are the most potent acid-suppressive pharmacologic agents available. Esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole substantially raise gastric pH for up to 24 hours after a single dose. The availability of an intravenous formulation of pantoprazole may help improve the treatment of SRMD in ICU patients, particularly those receiving mechanical ventilation. Tolerance does not develop, and few adverse effects have been reported.

CONCLUSIONS

Recent studies of PPIs have shown promising results in high-risk patients, making this class of drugs an option for the prophylaxis of SRMD.

Lipopolysaccharide-induced changes in rat gastric H/K-ATPase expression

OBJECTIVE

To evaluate lipopolysaccharide (LPS)-induced inhibition of gastric acid secretion.

SUMMARY BACKGROUND DATA

Endotoxemia from LPS inhibits gastric acid secretion by an unknown mechanism. Bacterial overgrowth in the stomach caused by decreased acid secretion could be responsible for nosocomial pneumonia developing in critically ill intensive care unit patients. Because acid secretion is via the H/K-ATPase and the effects of LPS on this enzyme are unknown, we hypothesized that LPS causes inhibition of gastric acid secretion by down-regulating the H/K-ATPase.

METHODS

A rat model to study gastric acid secretion was created. Saline or LPS (0.05-20 mg/kg IP) was given for 1 hour, after which basal acid secretion was determined for 1 hour. Pentagastrin (PG; 10 microg/kg IV) or saline was then given and gastric acid output collected for another 2 hours.

RESULTS

LPS dose dependently inhibited basal and PG stimulated acid secretion. LPS increased alpha- and beta-H/K-ATPase subunit mRNA expression (Northern blot) in the absence of PG compared with saline. In the presence of PG, LPS did not have this effect. Western blot analysis did not show any difference in alpha- or beta-subunit immunoreactivity. Immunofluorescence analysis demonstrated that PG increased staining in the secretory membranes for H/K-ATPase subunits whereas in all LPS-treated rats, it appeared that H/K-ATPase subunits remained within the tubulovesicles. Furthermore, changes in H/K-ATPase mRNA expression may not be related to changes in NF-kappaB activity.

CONCLUSIONS

These data suggest that inhibition of gastric acid secretion by LPS is due to inhibition of H/K-ATPase enzymatic function or changes in cytoskeletal rearrangements in H/K-ATPase subunits rather than by down-regulation of transcriptional or translational events.

Pharmaceutical strategies to prevent ventilator-associated pneumonia

The increasing incidence of hospital-acquired (nosocomial) infection is a disturbing phenomenon resulting in significant patient mortality and putting considerable strain on healthcare budgets and personnel. One particularly serious aspect of nosocomial infection is that of ventilator-associated pneumonia (VAP). This arises in patients who receive mechanical ventilation within the intensive care unit. The quoted incidence of VAP varies widely (5-67%) and the reported mortality of patients with VAP is in the range of 24-71%. This review will examine the many factors that account for these wide ranges reported, including the patient population under investigation, the causative organism, the method of diagnosis, interventions employed and preventative strategies. The use of bioactive and drug-impregnated biomaterials for endotracheal tube construction is discussed as novel approaches to the prevention of VAP.

Stress-related Mucosal Disease

Stress-related mucosal disease (SRMD) includes stress-related injury (superficial mucosal damage) and stress ulcers (focal deep mucosal damage). Both types are caused by mucosal ischemia, and both show a propensity for the acid-producing corpus and fundus. Prophylaxis of stress ulcers may reduce major bleeding but, so far, has not been shown to improve survival. The most widely used drugs for stress-related injury are the intravenous histamine H(2)-receptor antagonists. Proton pump inhibitors (PPIs) are the most potent acid-suppressive pharmacologic agents. The available PPIs significantly increase gastric pH for up to 24 hours after one dose. Tolerance does not develop, and adverse effects are few. Preliminary studies have demonstrated a significant reduction in SRMD bleeding for patients receiving PPI prophylaxis. PPIs may become an effective tool for reducing the incidence of SRMD in critically ill patients.

Bacterial translocation: clinical implications and prevention

The occurrence of BT has been well documented in experimental animal models of hemorrhagic shock, trauma, severe burns, cirrhosis, pancreatitis, and bacterial overgrowth. Translocation of viable bacteria and endotoxins into mesenteric lymph nodes and other gut-associated lymphatic tissue is thought to activate a complex interplay of mediators that initiates the SIRS. Multiple humoral and cellular systems cause synthesis, expression, and release of inflammatory mediators, such as toxic oxygen radicals, proteolytic enzymes, adherence molecules, and various cytokines. A massive sustained proinflammatory response can ultimately result in irreversible multiple organ dysfunction. Because BT is associated with splanchnic hypoperfusion, the cornerstone of therapy involves rapid resuscitation and restoration of tissue perfusion. If a septic focus can be identified, it should be removed. Gut protectants, promotility agents, antioxidants, and immune-enhancing diets have shown promise in improving length of survival in these critically ill patients.

The Economic Benefit of Practice Guidelines for Stress Ulcer Prophylaxis

The development of practice guidelines is an effective way to provide consistent and cost-effective patient care. Despite much progress in developing practice guidelines for various other clinical problems data documenting the efficacy of these guidelines are lacking. The purpose of this study was to compare usage patterns and cost effectiveness of a stress ulcer prophylaxis guideline in a trauma intensive care unit. The trauma intensive care unit team was observed for a 50-day period. Immediately after this period a stress ulcer prophylaxis guideline was implemented, and the team was again observed for a 50-day period. All information was recorded prospectively. The trauma intensive care unit team was blind to the existence of the study. The days of appropriate use of prophylaxis (ulcer prophylaxis prescribed per the practice guidelines) and inappropriate use (use other than per the practice guidelines) in each study phase and the resulting costs were calculated as the primary measurement of outcome. Forty-six patients were studied. The use of practice guidelines in the period after the guideline was implemented of the study reduced overall stress ulcer prophylaxis by 17 per cent ( P = 0.04). The appropriate prophylaxis was not significantly different when comparing the two periods of study; however, inappropriate use of prophylaxis (and associated charges) was statistically significantly less frequent after implementation of the practice guidelines. No patients developed clinically important gastrointestinal bleeding. The estimated annual savings of $102,895 in patient charges and $11,333 in actual drug costs in our trauma intensive care unit were due to the implementation of stress ulcer prophylaxis guidelines. We conclude that use of practice guidelines can significantly reduce patient charges without compromising patient care.

Role of acid suppressants in intensive care medicine

Bleeding from stress-induced mucosal lesions continues to be a potential problem in critically ill patients, although its incidence has decreased dramatically over the past decade. Patients considered to be at risk are those with respiratory failure, coagulopathy, severe burns or tetraplegia. The most important cause of stress ulcer bleeding is tissue hypoxia. Provided that appropriate dosage regimens are administered, all agents approved for stress ulcer prophylaxis may reduce the incidence of overt as well as clinically important bleeding. However, the efficacy of stress ulcer prophylaxis does not correlate with the efficacy of gastric acid inhibition. Although numerous studies have demonstrated that an alkaline gastric juice is associated with gastric Gram-negative bacterial overgrowth, controversy remains over whether the pharmacological suppression of gastric acid in critically ill patients facilitates nosocomial pneumonia. The reasons for these divergent results are discussed, as is a possible association between gastric acid suppression and other systemic infections. Finally, several cost-effectiveness analyses performed over recent years have demonstrated that, in properly selected critically ill patients, stress ulcer prophylaxis is cost-effective.

Gastrointestinal problems in the chronically critically ill patient

In summary, a variety of gastrointestinal processes may occur in the chronically critically ill patient population, usually as consequence of the primary systemic process. The clinical presentation is frequently nonclassic and there often is a substantial delay in diagnosis, resulting in increased morbidity and mortality.

Bleeding and pneumonia in intensive care patients given ranitidine and sucralfate for prevention of stress ulcer: meta-analysis of randomised controlled trials

OBJECTIVES

To determine the effectiveness of ranitidine and sucralfate in the prevention of stress ulcer in critical patients and to assess if these treatments affect the risk of nosocomial pneumonia.

DESIGN

Published studies retrieved through Medline and other databases. Five meta-analyses evaluated effectiveness in terms of bleeding rates (A: ranitidine v placebo; B: sucralfate v placebo) and infectious complications in terms of incidence of nosocomial pneumonia (C: ranitidine v placebo; D: sucralfate v placebo; E: ranitidine v sucralfate). Trial quality was determined with an empirical ad hoc procedure.

MAIN OUTCOME MEASURES

Rates of clinically important gastrointestinal bleeding and nosocomial pneumonia (compared between the two study arms and expressed with odds ratios specific for individual studies and meta-analytic summary odds ratios).

RESULTS

Meta-analysis A (five studies) comprised 398 patients; meta-analysis C (three studies) comprised 311 patients; meta-analysis D (two studies) comprised 226 patients: and meta-analysis E (eight studies) comprised 1825 patients. Meta-analysis B was not carried out as the literature search selected only one clinical trial. In meta-analysis A ranitidine was found to have the same effectiveness as placebo (odds ratio of bleeding 0.72, 95% confidence interval 0.30 to 1.70, P=0.46). In placebo controlled studies (meta-analyses C and D) ranitidine and sucralfate had no influence on the incidence of nosocomial pneumonia. In comparison with sucralfate, ranitidine significantly increased the incidence of nosocomial pneumonia (meta-analysis E: 1.35, 1.07 to 1.70, P=0.012). The mean quality score in the four analyses (on a 0 to 10 scale) ranged from 5.6 in meta-analysis E to 6.6 in meta-analysis A.

CONCLUSIONS

Ranitidine is ineffective in the prevention of gastrointestinal bleeding in patients in intensive care and might increase the risk of pneumonia. Studies on sucralfate do not provide conclusive results. These findings are based on small numbers of patients, and firm conclusions cannot presently be proposed.

Acute gastrointestinal bleeding in the intensive care unit. The gastroenterologist's perspective

Although SRES-associated hemorrhage previously constituted a significant cause of bleeding in the ICU, improvements in ICU management and the institution of prophylactic measures in high-risk patients have significantly reduced SRES-associated hemorrhage since the 1980s. Antacids, H2-receptor antagonists, and sucralfate have been shown to be effective in preventing clinically significant bleeding resulting from SRES, particularly when the intragastric pH is maintained at greater than 4. A selective approach should be adopted in SRES prophylaxis: Patients on mechanical ventilation, with coagulopathy, or with two of the other known risk factors should receive prophylaxis. Although the drug of choice depends to some extent on local preferences, an H2-receptor antagonist by continuous intravenous infusion may represent the best option. No pharmacologic therapy is of proven value once hemorrhage begins, but the current interventional techniques are effective in controlling hemorrhage. Gastrointestinal bleeding from NOMV has become less common with improvements in the hemodynamic monitoring of critically ill patients, but this disease must always be considered when lower gastrointestinal bleeding occurs in the context of relative hypoperfusion. For SRES and NOMV, treatment of the underlying disease or diseases is the optimal route to prevention.

Effects of intestinal ischemia/reperfusion injury on gastric acid secretion

BACKGROUND

The mechanism responsible for gastric colonization in critically injured ICU patients remains to be fully elucidated. Moreover, the effects of gut ischemia/reperfusion (I/R) injury on gastric function are unclear. It was our hypothesis that gut I/R injury would cause gastric dysfunction.

MATERIALS AND METHODS

Rats were anesthetized and, via laparotomy, the superior mesenteric artery (SMA) was clamped at its aortic origin for 45 min followed by clamp removal. Rats were allowed to awaken and then killed after 6 h of reperfusion. Control rats underwent laparotomy with SMA isolation. Stomachs were removed, gastric fluid was aspirated, and the volume, pH, and protein, bicarbonate, and glucose contents were determined. Serum and antral mucosa were prepared for gastrin radioimmunoassay and the glandular mucosa was assessed for morphologic injury.

RESULTS

SMA I/R injury caused significant accumulation of gastric luminal fluid that was alkaline and rich in protein, glucose, and bicarbonate content when compared with sham controls. SMA I/R injury also caused gastric surface epithelial cell injury and significantly increased serum and antral gastrin levels. In additional rats, gut I/R injury inhibited basal acid secretion and blunted the acid secretory response to pentagastrin.

CONCLUSIONS

This study demonstrated for the first time that small intestinal I/R injury causes significant gastric dysfunction. The findings suggest that this type of injury, a frequent occurrence in critically injured ICU patients, may predispose patients to gastric colonization due to stasis and loss of the natural bactericidal effects of gastric acid.

Trauma intensive care

Management of the traumatically injured patient in the intensive care unit is a complex and challenging area of general surgery. The problems encountered in the intensive care unit are the source of exciting clinical and basic science research. The future of caring for the severely injured patient suffering from the complications of trauma will undoubtedly further bond the art of clinical medicine to the accomplishments of developing technology and molecular biology.

The role of the gastrointestinal tract in postinjury multiple organ failure

Despite intensive investigation, the pathogenesis of postinjury multiple organ failure (MOF) remains elusive. Laboratory and clinical research strongly implicate that the gastrointestinal tract plays a pivotal role. Shock with resulting gut hypoperfusion appears to be one important inciting event. While early studies persuasively focused attention on bacterial translocation as a unifying mechanism to explain early and late sepsis syndromes that characterize postinjury MOF, subsequent studies suggest that other gut-specific mechanisms are operational. Based on our Trauma Research Center observations and those of others, we conclude that: 1) bacterial translocation may contribute to early refractory shock; 2) for patients who survive shock, the reperfused gut appears to be a source of proinflammatory mediators that may amplify the early systemic inflammatory response syndrome; and 3) early gut hypoperfusion sets the stage for progressive gut dysfunction such that the gut becomes a reservoir for pathogens and toxins that contribute to late MOF.

Helicobacter pylori infection in intensive care: increased prevalence and a new nosocomial infection

OBJECTIVE

The pathogenesis of acute gastric stress ulceration in the seriously ill is uncertain, and any role of Helicobacter pylori infection is unknown. We aimed to assess the relationship between H. pylori serological status and stress ulceration in seriously ill patients, as well as H. pylori serological status in intensive care nurses as a marker for nosocomial infection.

DESIGN

Prospective epidemiologic survey.

SETTING

Adult intensive care unit in a university teaching hospital.

PATIENTS

One hundred patients, 100 nurses, and 500 blood donors as community controls.

INTERVENTIONS

H. pylori serological status was measured in patients, staff, and controls using a rapid whole blood test. Upper gastrointestinal bleeding and risk factors for acute stress ulceration were recorded.

MEASUREMENTS AND MAIN RESULTS

In seriously ill patients, H. pylori seropositivity (67%) was significantly higher than in the control group (39%) (p < .001). In patients, seropositivity was not related to age, country of birth, diagnostic category, severity of illness, or risk score for stress ulceration. There was a trend toward increased macroscopic gastric bleeding in seropositive patients. In intensive care nurses, H. pylori seropositivity (40%) was significantly higher than in age-matched controls (19%) (p < .001). Only duration of intensive care nursing was significantly associated with seropositivity (p = .02).

CONCLUSIONS

The unexpectedly high H. pylori seropositivity rate in this seriously ill cohort raises the possibility that under intensive care conditions, H. pylori infection may modulate responses to illness and injury, with consequent clinical implications. Furthermore, the elevated seropositivity rate in intensive care nurses suggests that H. pylori can be nosocomially transmitted.

Gastrointestinal complications in the intensive care unit

Pathologic conditions affecting the abdomen are a significant cause of morbidity and mortality in the intensive care unit, but their importance is not widely recognized. This article presents several aspects of abdominal pathology that can occur in intensive care unit patients. This pathology may have a considerable impact on the prognosis and survival of the critically ill patient. The diagnostic contribution of laboratory tests and imaging is discussed. Conditions such as the abdominal compartment syndrome, acute mesenteric ischemia, gastrointestinal bleeding, diarrhea, abdominal sepsis, complications of entereal and parenteral nutrition, and ileus in critically ill patients are also reviewed.

Impact of trauma stress ulcer prophylaxis guidelines on drug cost and frequency of major gastrointestinal bleeding

Trauma patients are routinely prescribed stress ulcer prophylaxis despite evidence suggesting such therapy be limited to patients with identifiable risk factors for bleeding. With surgeons' consensus, we developed and implemented trauma stress ulcer prophylaxis guidelines, and measured the impact of clinical pharmacists on implementing the guidelines and the effect of the guidelines on drug cost and frequency of major gastrointestinal bleeding. Two groups of 150 consecutive patients admitted with multiple trauma were evaluated before and after guideline implementation and stratified by Injury Severity Score (ISS) to minor (ISS < 9) or moderate to severe (ISS > or = 9) trauma groups. The number of patients prescribed stress ulcer prophylaxis, length and cost of this therapy, and number of patients experiencing major gastrointestinal bleeding (decrease in consecutive hemoglobin > or = 2 g/dl in conjunction with coffee-ground emesis, hematemesis, melena, or hematochezia) were measured. All pharmacist interventions pertaining to stress prophylaxis were collected. Fewer patients were prescribed stress ulcer prophylaxis after guideline implementation (105/150, 70% vs 39/150, 26%, p<0.0001), leading to a decrease in total drug cost of $4558. Use decreased more in patients with minor (40/54, 74% vs 9/59, 15%, p<0.0001) than moderate to severe (65/96, 68% vs 30/91, 33%, p<0.0001) trauma. Neither length of therapy nor agent of choice (> 95% cimetidine) differed between groups. Fifteen (38%) of 38 postguideline prophylaxis orders were determined by the pharmacist not to meet guideline criteria. Recommendations to discontinue therapy were accepted in 9 (60%) of 15 instances. The frequency of major gastrointestinal bleeding remained unchanged between groups (1/150 vs 0/150, p=1.0). Implementation of trauma stress ulcer prophylaxis guidelines limiting therapy to patients with risk factors for bleeding led to a 80% decrease in drug cost and did not affect the frequency of major gastrointestinal bleeding.

A randomized, double-blind trial for stress ulcer prophylaxis shows no evidence of increased pneumonia

BACKGROUND

H2-receptor antagonists are commonly used for stress ulcer prophylaxis on intensive care units. However, there is evidence that via the route of an elevated gastric pH, followed by bacterial overgrowth and subsequent tracheal aspiration, pneumonia could occur. In line with this assumption total gastrectomized patients should develop a very high incidence of pneumonia, which is actually not the case. We therefore formulated the hypothesis that stress ulcer prophylaxis with H2-receptor antagonists does not lead to an increased pneumonia rate.

METHODS

A total of 158 patients with mechanical ventilation > or =48 hours of a surgical intensive care unit were randomized to the following groups: A, placebo (n = 57); B, pirenzepine (3 x 10 mg intravenously, n = 44); and C, ranitidine (3 x 50 mg intravenously, n = 57).

RESULTS

The pneumonia rate in ranitidine-, pirenzepine-, and placebo-treated patients is 10 of 57, 10 of 44, and 12 of 57, respectively.

CONCLUSIONS

Pneumonia rate is not adversely affected by H2-receptor antagonists in stress ulcer prophylaxis.

Incidence of infectious complications associated with the use of histamine2-receptor antagonists in critically ill trauma patients

OBJECTIVE

To determine the impact of histamine2 (H2)-receptor antagonist use on the occurrence of infectious complications in severely injured patients.

SUMMARY BACKGROUND DATA

Some previous studies suggest an increased risk of nosocomial pneumonia associated with the use of H2-receptor blockade in critically ill patients, but other investigations suggest an immune-enhancing effect of H2-receptor antagonists. The purpose of this study was to determine whether H2-receptor antagonist use affects the overall incidence of infectious complications.

METHODS

Patients enrolled in a randomized trial comparing ranitidine with sucralfate for gastritis prophylaxis were examined for all infectious complications during their hospitalization. Data on the occurrence of pneumonia were prospectively collected, and other infectious complications were retrospectively obtained from the medical record. The relative risk of infectious complications associated with ranitidine use and total infectious complications were analyzed.

RESULTS

Of 98 patients included, the charts of 96 were available for review. Sucralfate was given to 47, and 49 received ranitidine. Demographic factors were similar between the groups. Ranitidine use was associated with a 1.5-fold increased risk of developing any infectious complication (37 of 47 vs. 26 of 47; 95% confidence interval, 1.04 to 2.28). Infectious complications totaled 128 in the ranitidine-treated group and 50 in the sucralfate-treated group (p = 0.0014). These differences remained after excluding catheter-related infections (p = 0.0042) and secondary bacteremia (p = 0.0046).

CONCLUSIONS

Ranitidine use in severely injured patients is associated with a statistically significant increase in overall infectious complications when compared with sucralfate. These results indicate that ranitidine should be avoided where possible in the prophylaxis of stress gastritis.

The acute abdomen in the critically ill patient

The critically ill patient with an acute abdomen represents a great challenge for the surgeon. The physiologic derangement that is associated with the critically ill state both fuels and is fueled by acute abdominal processes. Improvements in critical care and cardiopulmonary bypass technique have allowed for a group of patients to evolve that are susceptible to the complications of prolonged flow states. This article focuses on the abdominal consequences of support of the critically ill patient, as well as, the diagnostic and therapeutic options that are available to treat these patients.

Ventilator-associated pneumonia: clinical significance and implications for nursing

Pneumonia is the second most common nosocomial infection in the United States and the leading cause of death from nosocomial infections. Intubation and mechanical ventilation greatly increase the risk of bacterial pneumonia. Ventilator-associated pneumonia (VAP) occurs in a patient treated with mechanical ventilation, and it is neither present nor developing at the time of intubation; it is a serious problem--with significant morbidity and mortality rates. Aspiration of bacteria from the oropharynx, leakage of contaminated secretions around the endotracheal tube, patient position, and cross-contamination from respiratory equipment and health care providers are important factors in the development of VAP. Nurses caring for patients treated with mechanical ventilation must recognize risk factors and include strategies for reducing these factors as part of their nursing care. This article summarizes the literature related to VAP: its incidence, associated factors, diagnosis, and current therapies, with an emphasis on nursing implications in the care of these patients.

Current guidelines on stress ulcer prophylaxis

Acute uppergastrointestinal bleeding in intensive care unit (ICU) patients may occur due to peptic ulcer disease, adverse drug effects, gastric tube lesions, acute renal failure, liver failure or stress-induced gastric mucosal lesions. Gastric acid hypersecretion can be observed in patients with head trauma or neurosurgical procedures. Gastric mucosal ischaemia due to hypotension and shock is the most important risk factor for stress ulcer bleeding. Preventive strategies aim to reduce gastric acidity (histamine H2 receptor antagonists, antacids), strengthen mucosal defensive mechanisms (sucralfate, antacids, pirenzepine) and normalise gastric mucosal microcirculation (sucralfate, pirenzepine). However, the most important prophylactic measure is an optimised resuscitation and ICU regime aiming to improve oxygenation and microcirculation. All drugs approved for stress ulcer prophylaxis in Europe (H2 antagonists, antacids, pirenzepine, sucralfate) have been shown to be effective in prospective controlled randomised trials. However, due to insufficient clinical data, prostaglandins and omeprazole cannot be recommended for this use. Stress ulcer prophylaxis is indicated only in patients at risk, and not in every ICU patient. The selection of drugs today depends not only on efficacy but also on possible adverse effects and on costs. In this regard, the most cost-effective drug is sucralfate. The clinical relevance of nosocomial pneumonia due to gastric bacterial overgrowth has decreased during the past decade due to several changes in the management of critically ill patients.

Impacting cost and appropriateness of stress ulcer prophylaxis at a university medical center

OBJECTIVE

To determine the appropriateness and medication cost of stress ulcer prophylaxis before and after a targeted educational intervention.

DESIGN

In the preintervention cohort (phase 1), 264 patients were evaluated over 2 months, using stress ulcer prophylaxis guidelines developed by a comprehensive literature search. Targeted educational programs were subsequently used to inform trauma housestaff on appropriate usage of stress ulcer prophylaxis medications with emphasis on using sucralfate. The postintervention cohort (phase 2) involved concurrent evaluation of 279 patients. Length of inappropriate stress ulcer prophylaxis (i.e., did not meet approved guidelines) between phases was compared using a Student's t-test for independent samples (alpha = .05).

SETTING

A 365-bed university medical center.

PATIENTS

Patients admitted to any of the intensive care units and all patients who were placed on histamine-2-antagonists or sucralfate for stress ulcer prophylaxis.

INTERVENTIONS

Educational intervention regarding appropriate stress ulcer prophylaxis directed at the trauma service.

MEASUREMENTS AND MAIN RESULTS

Patient demographics in the two phases were similar and there was no difference in the number of patient risk factors for stress-induced bleeding. The mean length of inappropriate stress ulcer prophylaxis was 5.78 +/- 4.36 days in phase 1 and 4.66 +/- 3.10 days in phase 2 (p < .05). Eighty-nine patients in phase 1 received inappropriate stress ulcer prophylaxis for a drug cost of $2,272.00 (mean $25.53 +/- 25.52) compared with 90 patients in phase 2 with a drug cost of $1,417.00 (mean $15.75 +/- 13.06). Three patients in each phase had clinically important bleeding (hemodynamic compromise or transfusion); all were receiving ranitidine. The mean total cost (fixed and variable) of hospitalization was $69,288.00 and $74,709.00 for the three patients who bled in each phase compared with $19,850.00 and $15,812.00 for all patients admitted to the intensive care unit in phases 1 and 2, respectively. The mean length of hospital stay was 30.00 days and 29.33 days for the three patients who bled in each phase compared with 11.54 days and 10.27 days for all patients admitted to the intensive care unit in phases 1 and 2, respectively.

CONCLUSIONS

Cost savings are associated with more appropriate stress ulcer prophylaxis. Clinically important bleeding is uncommon but results in prolonged hospital stays and increased costs.

Comparison of omeprazole and ranitidine for stress ulcer prophylaxis

Stress ulcer prophylaxis protects against clinically important gastrointestinal bleeding and has gained widespread use. This study compares the efficacy of omeprazole to ranitidine for this indication. This was a prospective, randomized clinical trial. Sixty-seven high-risk patients were randomized to receive either ranitidine 150 mg (N = 35) intravenously daily or omeprazole 40 mg (N = 32) daily orally or by nasogastric route. Patients were monitored for clinically important bleeding. There was no statistically significant difference between treatment groups in the number of patients enrolled, gender, race, or age. The study groups were comparable in regard to the severity of illness based on their similar APACHE II score, duration of ICU stay, duration of ventilator dependence, and mortality rate. A significant difference was found only in regard to the number of risk factors per patient. The ranitidine-treated group had 2.7 risk factors per patient while the omeprazole-treated group had 1.9 (P < 0.05). Eleven patients (31%) given ranitidine and two patients (6%) given omeprazole developed clinically important bleeding (P < 0.05). Nosocomial pneumonia developed in five patients (14%) receiving ranitidine and one patient (3%) receiving omeprazole (P > 0.05). We conclude that oral omeprazole is safe, effective, and clinically feasible for stress ulcer prophylaxis.

Comparison of omeprazole and ranitidine for stress ulcer prophylaxis

Stress ulcer prophylaxis protects against clinically important gastrointestinal bleeding and has gained widespread use. This study compares the efficacy of omeprazole to ranitidine for this indication. This was a prospective, randomized clinical trial. Sixty-seven high-risk patients were randomized to receive either ranitidine 150 mg (N = 35) intravenously daily or omeprazole 40 mg (N = 32) daily orally or by nasogastric route. Patients were monitored for clinically important bleeding. There was no statistically significant difference between treatment groups in the number of patients enrolled, gender, race, or age. The study groups were comparable in regard to the severity of illness based on their similar APACHE II score, duration of ICU stay, duration of ventilator dependence, and mortality rate. A significant difference was found only in regard to the number of risk factors per patient. The ranitidine-treated group had 2.7 risk factors per patient while the omeprazole-treated group had 1.9 (P < 0.05). Eleven patients (31%) given ranitidine and two patients (6%) given omeprazole developed clinically important bleeding (P < 0.05). Nosocomial pneumonia developed in five patients (14%) receiving ranitidine and one patient (3%) receiving omeprazole (P > 0.05). We conclude that oral omeprazole is safe, effective, and clinically feasible for stress ulcer prophylaxis.

Nosocomial pneumonia in ventilated trauma patients during stress ulcer prophylaxis with sucralfate, antacid, and ranitidine

OBJECTIVE

To compare the incidence of nosocomial pneumonia in critically injured patients randomized to one of three stress ulcer prophylaxis regimens.

DESIGN

Prospective, randomized clinical trial.

METHODS

Mechanically ventilated patients admitted to the trauma intensive care unit of a Level I trauma center received sucralfate, antacid, or ranitidine.

MEASUREMENTS AND MAIN RESULTS

Two hundred forty-two patients were randomized: sucralfate, n = 80; antacid, n = 82; and ranitidine, n = 80. There was no statistically significant difference in pneumonia rates among the treatment groups (p = 0.875). Pneumonia occurred more frequently in patients with gram-negative retrograde colonization from stomach to trachea (p = 0.02), but this accounted for only 13% of all pneumonias in the study population. The death rate in patients with pneumonia was not statistically different among the three groups. Although 20% developed overt gastrointestinal bleeding, no episode was clinically significant. Mean gastric pH was > 4 in 95% of the study population, including 88% of patients receiving sucralfate. The death rate in the antacid group was significantly higher (p = 0.046) but not because of increased gastrointestinal bleeding or pneumonia.

CONCLUSIONS

Our results show no difference in the incidence of nosocomial pneumonia in mechanically ventilated trauma patients during the first 4 days of stress ulcer prophylaxis with sucralfate, antacid, or ranitidine. There is a trend toward decreased pneumonia in the sucralfate group after study day 4. Even after controlling for injury severity, the mortality rate in the antacid group was significantly higher; the reasons for this are unknown.