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MacLaren R, Dionne JC, Granholm A, Alhazzani W, Szumita PM, Olsen K, Barletta JF, Møller MH, Karvellas CJ, Wischmeyer P, DePriest A, Carlos V, Argetsinger D, Carothers JJ, Lee R, Napolitano L, Perri D, Naylor DF. Society of Critical Care Medicine and American Society of Health-System Pharmacists Guideline for the Prevention of Stress-Related Gastrointestinal Bleeding in Critically Ill Adults. Crit Care Med 2024; 52:e421-e430. [PMID: 39007578 DOI: 10.1097/ccm.0000000000006330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
RATIONALE Critically ill adults can develop stress-related mucosal damage from gastrointestinal hypoperfusion and reperfusion injury, predisposing them to clinically important stress-related upper gastrointestinal bleeding (UGIB). OBJECTIVES The objective of this guideline was to develop evidence-based recommendations for the prevention of UGIB in adults in the ICU. DESIGN A multiprofessional panel of 18 international experts from dietetics, critical care medicine, nursing, and pharmacy, and two methodologists developed evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guideline development including task force selection and voting. METHODS The panel members identified and formulated 13 Population, Intervention, Comparison, and Outcome questions. We conducted a systematic review for each question to identify the best available evidence, statistically analyzed the evidence, and then assessed the certainty of the evidence using the GRADE approach. We used the evidence-to-decision framework to formulate the recommendations. Good practice statements were included to provide additional guidance. RESULTS The panel generated nine conditional recommendations and made four good practice statements. Factors that likely increase the risk for clinically important stress-related UGIB in critically ill adults include coagulopathy, shock, and chronic liver disease. There is no firm evidence for mechanical ventilation alone being a risk factor. Enteral nutrition probably reduces UGIB risk. All critically ill adults with factors that likely increase the risk for stress-related UGIB should receive either proton pump inhibitors or histamine-2 receptor antagonists, at low dosage regimens, to prevent UGIB. Prophylaxis should be discontinued when critical illness is no longer evident or the risk factor(s) is no longer present despite ongoing critical illness. Discontinuation of stress ulcer prophylaxis before transfer out of the ICU is necessary to prevent inappropriate prescribing. CONCLUSIONS The guideline panel achieved consensus regarding the recommendations for the prevention of stress-related UGIB. These recommendations are intended for consideration along with the patient's existing clinical status.
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Affiliation(s)
- Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - Joanna C Dionne
- Division of Gastroenterology and Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anders Granholm
- Department of Intensive Care, Righospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Waleed Alhazzani
- Division of Gastroenterology and Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Division of Critical Care, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Paul M Szumita
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA
| | - Keith Olsen
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Jeffrey F Barletta
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Glendale, AZ
| | - Morten Hylander Møller
- Department of Intensive Care, Righospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Constantine J Karvellas
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Paul Wischmeyer
- Department of Anesthesiology and Surgery, Duke University Medical Center, Durham, NC
| | - Ashley DePriest
- Department of Food and Nutrition, Emory Healthcare, Atlanta, GA
| | | | | | - John J Carothers
- Department of Inpatient Pharmacy, United States Public Health Service, Alaska Native Medical Center, Anchorage, AK
| | - Rosemary Lee
- Critical Care and Progressive Care Units, Baptist Health South Florida, Miami, FL
| | - Lena Napolitano
- Acute Care Surgery, Surgical Critical Care, Department of Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Dan Perri
- Division of Gastroenterology and Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Divisions of Clinical Pharmacology & Toxicology and Critical Care Medicine, Department of Medicine, McMaster University, Hamiton, ON, Canada
| | - Douglas F Naylor
- Department of Surgery-Trauma Surgery, Critical Care, and Acute Care Surgery, University Hospitals of Cleveland, Cleveland, OH
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MacLaren R, Dionne JC, Granholm A, Alhazzani W, Szumita PM, Olsen K, Barletta JF, Møller MH, Karvellas CJ, Wischmeyer P, DePriest A, Carlos V, Argetsinger D, Carothers JJ, Lee R, Napolitano L, Perri D, Naylor DF. Executive Summary-Society of Critical Care Medicine Guideline and American Society of Health-System Pharmacists for the Prevention of Stress-Related Gastrointestinal Bleeding in Critically Ill Adults. Crit Care Med 2024; 52:1295-1299. [PMID: 39007570 DOI: 10.1097/ccm.0000000000006329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Affiliation(s)
- Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - Joanna C Dionne
- Division of Gastroenterology and Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anders Granholm
- Department of Intensive Care, Righospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Waleed Alhazzani
- Division of Gastroenterology and Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Division of Critical Care, Department of Medicine, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Paul M Szumita
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA
| | - Keith Olsen
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Jeffrey F Barletta
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Glendale, AZ
| | - Morten Hylander Møller
- Department of Intensive Care, Righospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Constantine J Karvellas
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine University of Alberta, Edmonton, AB, Canada
| | - Paul Wischmeyer
- Department of Anesthesiology and Surgery, Duke University Medical Center, Durham, NC
| | - Ashley DePriest
- Department of Food and Nutrition, Emory Healthcare, Atlanta, GA
| | | | | | - John J Carothers
- Department of Inpatient Pharmacy, United States Public Health Service, Alaska Native Medical Center, Anchorage, AK
| | - Rosemary Lee
- Critical Care and Progressive Care Units, Baptist Health South Florida, Miami, FL
| | - Lena Napolitano
- Acute Care Surgery, Surgical Critical Care, Department of Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Dan Perri
- Division of Gastroenterology and Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Divisions of Clinical Pharmacology & Toxicology and Critical Care Medicine, Department of Medicine, McMaster University, Hamiton, ON, Canada
| | - Douglas F Naylor
- Department of Surgery-Trauma Surgery, Critical Care, and Acute Care Surgery, University Hospitals of Cleveland, Cleveland, OH
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Tekir Yılmaz E, Olgun Keleş B. Biopsy-Proven Gastric Pathological Findings in Mechanically Ventilated Intensive Care Unit Patients. Cureus 2024; 16:e61744. [PMID: 38975530 PMCID: PMC11226191 DOI: 10.7759/cureus.61744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2024] [Indexed: 07/09/2024] Open
Abstract
Objectives Helicobacter pylori (H. pylori) is known to affect a large proportion of the world population. It plays a role in the pathogenesis of peptic ulcer (PU) and increases the likelihood of bleeding. In critically ill patients in intensive care units (ICUs), the risk of bleeding may be much higher due to many concomitant factors. The study aimed to determine the activation of H. pylori in mechanically ventilated (MV) intensive care patients and compare this with the general population. Methods This study was performed retrospectively by screening patients who underwent esophagogastroduodenoscopy and histopathological sampling in our hospital between January and June 2023. The study included 79 patients aged between 18 and 85 years. The patients were categorized into two groups: 35 patients in the ICU with mechanical ventilation (MV) support (EMV) and 44 patients who presented to the gastroenterology department due to dyspeptic symptoms and underwent endoscopy (ED). Age; sex characteristics; laboratory parameters such as hemoglobin (Hb), hematocrit (Htc), mean cellular volume (MCV), white blood cell (WBC), neutrophil, platelet, glucose, urea, creatinine, aspartate transaminase (AST), alanine transaminase (ALT), C-reactive protein (CRP), albumin, ferritin, thyroid-stimulating hormone (TSH), anti-hepatitis C virus (HCV), hepatitis B surface antigen (HBsAg), anti-HIV; and biopsy results (H. pylori positivity, intestinal metaplasia, and atrophy) were recorded. Results A total of 79 patients who underwent gastric biopsy were assessed. There were 35 patients in the EMV group and 44 patients in the ED group. There was no difference in gender and age distribution between the groups. Hb and Htc were significantly lower in EMV compared to ED (p=0.001). Hb was 9.4±1.7 g/dL in EMV and 10.8±2.1 g/dL in ED. Htc was 29.6±5.1 in EMV and 33.5±5.7 in ED. MCV, WBC, glucose, urea, AST, ALT, CRP, and ferritin values were statistically significantly higher in EMV (p<0.05). Albumin and creatinine levels were statistically significantly lower in EMV (p<0.05). There was no significant difference between the groups in terms of neutrophils, platelets, and TSH. In the EMV group, H. pylori activity was negative in 31 (88.6%) patients and positive in four (11.4%) patients. In the ED group, H. pylori activity was negative in 30 (68.2%) patients and positive in 14 (31.8%) patients. There was a statistically significant difference between the groups in terms of H. pylori positivity (p=0.032). Conclusions The prevalence of H. pylori in MV patients in the ICU is low compared to the average population. The incidence of atrophic gastritis and intestinal metaplasia is the same. The present study supports that ICU cases do not have a higher risk of gastric premalignant lesions compared to the average population.
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Affiliation(s)
- Elvan Tekir Yılmaz
- Anesthesiology and Reanimation, Giresun University the Faculty of Medicine, Giresun, TUR
| | - Bilge Olgun Keleş
- Anesthesiology and Reanimation, Giresun University the Faculty of Medicine, Giresun, TUR
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Aida K, Azuma K, Mishima S, Ishii Y, Suzuki S, Oda J. Potentially inappropriate medications at discharge among elderly patients at a single tertiary emergency medical institution in Japan: a retrospective cross-sectional observational study. Acute Med Surg 2021; 8:e711. [PMID: 34876989 PMCID: PMC8628299 DOI: 10.1002/ams2.711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/30/2021] [Accepted: 11/03/2021] [Indexed: 11/15/2022] Open
Abstract
Aim Potentially inappropriate medications (PIMs) are associated with a lower medication adherence and a higher incidence of adverse events and medical costs among elderly patients. The current study aimed to examine the prescription status of elderly patients transported to tertiary emergency medical institutions to compare the proportion of elderly patients using PIMs at admission and discharge and to investigate the characteristics of PIMs at discharge and their associated factors. Methods In total, 264 patients aged 75 years or older who were transferred to and discharged from the emergency room at Tokyo Medical University Hospital, a tertiary care hospital, from September 2018 to August 2019 were included in this study. We quantified the number of PIMs at admission and discharge based on the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP) criteria version 2. The primary outcomes were the proportion of elderly patients taking at least one PIM at admission and discharge. Results The proportions of patients taking PIMs at admission and discharge were 55% (n = 175) and 28% (n = 74), respectively. Old age, greater number of PIMs at admission, and greater number of medications at discharge were directly associated with PIMs at discharge. Conclusions Admission to tertiary care hospitals resulted in a lower number of prescribed PIMs. Elderly patients with a higher number of PIMs at admission and higher number of medications at discharge might have been prescribed with PIMs.
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Affiliation(s)
- Kenta Aida
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Kazunari Azuma
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Shiro Mishima
- Department of Medical Safety Management Tokyo Medical University Tokyo Japan
| | - Yuri Ishii
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Shoji Suzuki
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Jun Oda
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
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Xing XX, Zhu C, Chu YQ, Bai XR, Wang K, Zhang ST, Yan SY. Physicians' knowledge, attitude, and prescribing behavior regarding stress ulcer prophylaxis in China: a multi-center study. BMC Gastroenterol 2021; 21:402. [PMID: 34696716 PMCID: PMC8547063 DOI: 10.1186/s12876-021-01979-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 10/12/2021] [Indexed: 02/04/2023] Open
Abstract
Background Perioperative patients are at risk of developing stress ulcers (SU), which can cause clinically important bleeding. Stress ulcer prophylaxis (SUP) is widely applied to the patients in Intensive care unit (ICU) as well as the general ward, so it may lead to overmedication. However, there have been no surveys regarding SUP knowledge or prescribing habits.
Objective Our study assessed the knowledge, attitudes, and prescribing behavior of the surgeons toward perioperative patients regarding SUP and determined factors associated with low knowledge and high level of prescribing behaviors. Methods We performed a cross-sectional survey using questionnaires, randomly sampling 1266 surgeons on their current SUP practices. Results Proton pump inhibitors for SUP were used the most (94%); 43% used lansoprazole. Guideline awareness was inconsistent; the most familiar guideline was the National Medical Journal of China, and 46% were unaware of any guidelines. The predictors of low knowledge score regarding SUP in multivariable analysis were the hospital grade (p = 0.000), the type of hospital (p = 0.044), attendance at continuing education programs (p = 0.037), the awareness of clinical practice guidelines (CPGs) for SUP (p = 0.000). Twenty-one percent of physicians were high prescribers. High prescribing behavior was associated with hospital grade(p = 0.000), education level(p = 0.010) and attendance at continuing education programs (p = 0.000). Conclusion We found that most surgeons used SUP, primarily proton pump inhibitors. However, surgeons knew little about the SUP guidelines, which may lead to insufficient SUP knowledge and overmedication. In addition, hospital grade, the type of hospital and attendance at continuing education programs may also affect the low knowledge of SUP. Hospital grade, education level and attendance at continuing education programs may affect high prescribing behavior.
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Affiliation(s)
- Xiao Xuan Xing
- Department of Pharmacy, Xuanwu Hospital of Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Beijing, People's Republic of China
| | - Chen Zhu
- Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Yan Qi Chu
- Department of Pharmacy, Xuanwu Hospital of Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Beijing, People's Republic of China
| | - Xiang Rong Bai
- Department of Pharmacy, Xuanwu Hospital of Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Beijing, People's Republic of China
| | - Ke Wang
- Department of Pharmacy, Xuanwu Hospital of Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Beijing, People's Republic of China
| | - Si Tao Zhang
- Department of Pharmacy, Xuanwu Hospital of Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Beijing, People's Republic of China
| | - Su Ying Yan
- Department of Pharmacy, Xuanwu Hospital of Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, People's Republic of China. .,National Clinical Research Center for Geriatric Disorders, Beijing, People's Republic of China.
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
Stress ulcer prophylaxis (SUP) with acid-suppressive drug therapy is widely utilized in critically ill patients following neurologic injury for the prevention of clinically important stress-related gastrointestinal bleeding (CIB). Data supporting SUP, however, largely originates from studies conducted during an era where practices were vastly different than what is considered routine by today's standard. This is particularly true in neurocritical care patients. In fact, the routine provision of SUP has been challenged due to an increasing prevalence of adverse drug events with acid-suppressive therapy and the perception that CIB rates are sparse. This narrative review will discuss current controversies with SUP as they apply to neurocritical care patients. Specifically, the pathophysiology, prevalence, and risk factors for CIB along with the comparative efficacy, safety, and cost-effectiveness of acid-suppressive therapy will be described.
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Barletta JF, Buckley MS, MacLaren R. The SUP-ICU Trial: Does It Confirm or Condemn the Practice of Stress Ulcer Prophylaxis? Hosp Pharm 2019; 55:96-101. [PMID: 32214442 DOI: 10.1177/0018578719867687] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose: Stress ulcer prophylaxis (SUP) is routinely administered to critically ill patients for the prevention of stress ulcer-induced, clinically important bleeding (CIB). Recently, the value of SUP has been questioned due to the perceived decline in CIB and the potential for infectious complications secondary to acid suppressive therapy. The SUP-ICU trial is a large, randomized controlled trial comparing intravenous pantoprazole with placebo for the indication of SUP. It is hoped that this trial would answer many of the questions pertaining to the overall value of SUP. This article will provide an in-depth assessment of the SUP-ICU trial in the context of the overall body of literature in this area. Furthermore, applications for clinical practice and recommendations on the provision of SUP are provided. Summary: The SUP-ICU trial revealed no difference in the primary outcome of 90-day mortality with pantoprazole but lower rates of CIB were noted (which was a secondary outcome). Overall, these data provide important insight into the value of SUP along with other questions related to the provision of SUP such as the relationship between CIB and mortality, infectious complications, and enteral nutrition. Conclusions: The SUP-ICU trial is a landmark trial describing the value of SUP in a modern-day setting of intensive care unit (ICU) practice. The provision of SUP should be continued in high-risk patients. Future studies are ongoing that will add further insight to this routine practice.
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Horsa BA, Ayele Y, Ayalew MB. Assessment of pharmacologic prophylaxis use against stress ulcer in the medical wards of University of Gondar Hospital. SAGE Open Med 2019; 7:2050312119827409. [PMID: 30746144 PMCID: PMC6360640 DOI: 10.1177/2050312119827409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 01/07/2019] [Indexed: 12/13/2022] Open
Abstract
Background Critically ill patients with moderate-to-severe physiologically stressful event are at high risk of developing stress ulcers. The use of pharmacological prophylaxis significantly reduces the incidence of stress ulcer in high-risk patients. Objective The aim of this study was to assess the use of pharmacological prophylaxis for stress ulcer in the medical wards of University of Gondar Hospital. Methods A cross-sectional study design was used. In total, 234 patients were selected through simple random sampling technique. The risk of stress ulcer development was assessed using Evidence-Based Medicine Guideline for stress ulcer prepared by Orlando Regional Medical Center. SPSS version 21 was used for data analysis. Result The most common acute risk factor to stress ulcer was coagulopathy (18.4%), followed by hypoperfusion (9.8%). The concomitant non-steroidal anti-inflammatory drug use (16.7%), mild-to-moderate brain or spinal cord injury (11.1%), and concomitant or recent corticosteroid use (9.4%) were frequently seen risk factors that necessitate administration of a prophylaxis. In total, 82 (35%) study participants were given stress ulcer prophylaxis, among which 52 (63.4%) were given without indication. The most commonly used drug class in the prevention of stress ulcer was proton pump inhibitors (76/82, 92.7%). In total, 43 (18.4%) study subjects were not given stress ulcer prophylaxis while there was clear indication. Patients with a long hospital stay and a diagnosis of central nervous system disorders had significant risk for inappropriate stress ulcer prophylaxis use. Conclusion In this study, inappropriate use of prophylaxis for stress ulcer was common. The higher proportion of inappropriateness was due to the use of stress ulcer prophylaxis while there was no enough indication. We recommend future researchers to assess the cost and impact of inappropriate stress ulcer prophylaxis use, and the physicians should be adherent to the standard guidelines.
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Affiliation(s)
- Boressa Adugna Horsa
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Yohanes Ayele
- Department of Clinical Pharmacy, School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Mohammed Biset Ayalew
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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The Acute Influence of Acid Suppression with Esomeprazole on Gastrointestinal Microbiota and Brain Gene Expression Profiles in a Murine Model of Restraint Stress. Neuroscience 2019; 398:206-217. [DOI: 10.1016/j.neuroscience.2018.11.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 11/28/2018] [Accepted: 11/29/2018] [Indexed: 12/17/2022]
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med 2017; 45:486-552. [PMID: 28098591 DOI: 10.1097/ccm.0000000000002255] [Citation(s) in RCA: 1889] [Impact Index Per Article: 269.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012." DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017; 43:304-377. [PMID: 28101605 DOI: 10.1007/s00134-017-4683-6] [Citation(s) in RCA: 3705] [Impact Index Per Article: 529.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/06/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012". DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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Abstract
PURPOSE OF REVIEW Stress ulcer prophylaxis (SUP) is considered standard of care in the majority of critically ill patients in the ICU. In this review, we will present the current evidence for the use of SUP in ICU patients, including data on the prevalence of gastrointestinal bleeding and the balance between benefits and harms of SUP. RECENT FINDINGS The prevalence of overt gastrointestinal bleeding in critically ill patients is in the area of 5%. Consistent risk factors for gastrointestinal bleeding have been identified, but indications for SUP vary considerably. SUP is used in three out of four critically ill patients, most frequently in the form of proton pump inhibitors. A recent systematic review of SUP vs. placebo or no prophylaxis in critically ill patients highlights the lack of evidence supporting the use of SUP. Importantly, data suggest potential harm, including increased risk of nosocomial infections and cardiovascular events. SUMMARY The prevalence of gastrointestinal bleeding in critically ill patients in the ICU is low, the prognostic importance is ambiguous, and SUP is widely used. The balance between benefits and harms of SUP is unknown, and clinical equipoise exists. High-quality randomized controlled trials and systematic reviews assessing benefits and harms of SUP in ICU patients are highly warranted.
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Lu T, Guan J. Combined application of nasogastric tubes and nasointestinal tubes in neurosurgical intensive care patients with stress ulceration: a novel solution to treatment and early enteral nutrition. SPRINGERPLUS 2016; 5:1769. [PMID: 27795911 PMCID: PMC5059544 DOI: 10.1186/s40064-016-3431-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 09/29/2016] [Indexed: 12/31/2022]
Abstract
Objective
Stress ulcers occur frequently in neurosurgical intensive care patients and can pose serious risks. We summarized the clinical experience of the combined application of nasointestinal tubes for early restoration of enteral nutrition and of nasogastric (NG) tubes for stress ulceration treatment in patients hospitalized in a neurosurgical intensive care unit. Methods From January 2011 to June 2011, a series of 67 patients with stress ulceration hospitalized in a neurosurgical intensive care unit were randomized to two groups. The control group (33 patients) received treatment with NG tube decompression and drainage according to international guidelines, and parenteral nutrition was changed to enteral feeding until there was no grossly visible blood in the NG tube. The nasointestinal tube group (34 patients) received treatment combining application of NG tubes and nasointestinal tubes. Drainage was performed with NG tubes as in the control group, with concurrent placement of nasointestinal tubes. Duration until resolution of stress ulceration and days until start of enteral nutrition were compared between the two groups. Results Duration until resolution of stress ulceration was 4.5 days in the control group and 4.3 days in the nasointestinal tube group. There was no difference between the two groups (P > 0.05). Duration until start of enteral nutrition was 4.5 days in the control group and 1 day in the nasointestinal tube group. There was an obvious difference between the two groups (P < 0.01). Conclusions The combined application of NG tubes and nasointestinal tubes in neurosurgical intensive care patients with stress ulceration is an effective means of treating stress ulceration and restoring early enteral nutrition.
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Affiliation(s)
- Tianshu Lu
- Department of Neurosurgery, The General Hospital of Shenyang Military Region, No. 83 Cultural Road, Shenyang, 110840 China
| | - Jingyu Guan
- Department of Neurosurgery, The General Hospital of Shenyang Military Region, No. 83 Cultural Road, Shenyang, 110840 China
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15
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Rafinazari N, Abbasi S, Farsaei S, Mansourian M, Adibi P. Adherence to stress-related mucosal damage prophylaxis guideline in patients admitted to the Intensive Care Unit. J Res Pharm Pract 2016; 5:186-92. [PMID: 27512710 PMCID: PMC4966238 DOI: 10.4103/2279-042x.185728] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Objective: Concern about adverse effects of the inconsistent use of stress-related mucosal damage prophylaxis in intensive care unit (ICU) is increasing. Hence, this study was designed to prospectively evaluate the rate of inappropriate stress ulcer prophylaxis (SUP) administration upon ICU admission, at ICU discharge and determine the adherence to American Society of Health-System Pharmacists (ASHP) guideline during ICU stay. Methods: In this study, 200 patients were randomly selected from all ICU admissions during 9 months. Risk factors of stress ulcer were recorded daily during ICU stay and appropriateness of SUP administration was assessed according to the ASHP criteria. Findings: Of all 160 (80%) patients who received SUP, 44.4% did not have indication; and among 95 patients with an indication for SUP administration, 6.3% did not receive it upon ICU admission. Consequently, 77 (38.5%) of 200 patients received inappropriate prophylaxis on ICU admission. In addition, 53.5% of patients had appropriate adherence to ASHP guideline during all days of ICU stay (44% and 2.5% of patients received SUP more than 120% and <80% of appropriate SUP duration, respectively). Moreover, 81.2% were continued on inappropriate prophylaxis upon transfer from the ICU. Conclusion: We concluded that although SUP administration included both overutilization and underutilization in this ICU, but high prevalence of SUP overutilization caused unnecessary hospital costs, personal monetary burden, and may increase adverse drug reactions. Therefore, educating physicians and cooperation of clinical pharmacists regarding implementing standard protocols could improve patterns of SUP administration.
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Affiliation(s)
- Niloofar Rafinazari
- Department of Clinical Pharmacy and Pharmacy Practice, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeed Abbasi
- Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shadi Farsaei
- Department of Clinical Pharmacy and Pharmacy Practice, Isfahan Pharmaceutical Sciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Marjan Mansourian
- Department of Biostatistics, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Peyman Adibi
- Department of Gastroenterology, Integrative Functional Gastroenterology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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16
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Shears M, Alhazzani W, Marshall JC, Muscedere J, Hall R, English SW, Dodek PM, Lauzier F, Kanji S, Duffett M, Barletta J, Alshahrani M, Arabi Y, Deane A, Cook DJ. Stress ulcer prophylaxis in critical illness: a Canadian survey. Can J Anaesth 2016; 63:718-24. [DOI: 10.1007/s12630-016-0612-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 01/18/2016] [Accepted: 02/04/2016] [Indexed: 01/31/2023] Open
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17
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KRAG M, PERNER A, WETTERSLEV J, WISE MP, BORTHWICK M, BENDEL S, MCARTHUR C, COOK D, NIELSEN N, PELOSI P, KEUS F, GUTTORMSEN AB, MOLLER AD, MØLLER MH. Stress ulcer prophylaxis in the intensive care unit: an international survey of 97 units in 11 countries. Acta Anaesthesiol Scand 2015; 59:576-85. [PMID: 25880349 DOI: 10.1111/aas.12508] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 02/09/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND Stress ulcer prophylaxis (SUP) may decrease the incidence of gastrointestinal bleeding in patients in the intensive care unit (ICU), but the risk of infection may be increased. In this study, we aimed to describe SUP practices in adult ICUs. We hypothesised that patient selection for SUP varies both within and between countries. METHODS Adult ICUs were invited to participate in the survey. We registered country, type of hospital, type and size of ICU, preferred SUP agent, presence of local guideline, reported indications for SUP, criteria for discontinuing SUP, and concerns about adverse effects. Fisher's exact test was used to assess differences between groups. RESULTS Ninety-seven adult ICUs in 11 countries participated (eight European). All but one ICU used SUP, and 64% (62/97) reported having a guideline for the use of SUP. Proton pump inhibitors were the most common SUP agent, used in 66% of ICUs (64/97), and H2-receptor antagonists were used 31% (30/97) of the units. Twenty-three different indications for SUP were reported, the most frequent being mechanical ventilation. All patients were prescribed SUP in 26% (25/97) of the ICUs. Adequate enteral feeding was the most frequent reason for discontinuing SUP, but 19% (18/97) continued SUP upon ICU discharge. The majority expressed concern about nosocomial pneumonia and Clostridium difficile infection with the use of SUP. CONCLUSIONS In this international survey, most participating ICUs reported using SUP, primarily proton pump inhibitors, but many did not have a guideline; indications varied considerably and concern existed about infectious complications.
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Affiliation(s)
- M. KRAG
- Department of Intensive Care 4131; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
| | - A. PERNER
- Department of Intensive Care 4131; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
| | - J. WETTERSLEV
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
| | - M. P. WISE
- Department of Adult Critical Care; University Hospital of Wales; Cardiff UK
| | - M. BORTHWICK
- Pharmacy Department; Oxford University Hospitals NHS Trust; Oxford UK
| | - S. BENDEL
- Department of Intensive Care Medicine; Kuopio University Hospital; Kuopio Finland
| | - C. MCARTHUR
- Department of Critical Care Medicine; Auckland City Hospital; Auckland New Zealand
| | - D. COOK
- Department of Medicine; McMaster University; Hamilton Ontario Canada
| | - N. NIELSEN
- Department of Anaesthesiology and Intensive Care; Helsingborg Hospital; Sweden and Department of Clinical Sciences; Lund University; Lund Sweden
| | - P. PELOSI
- Department of Surgical Sciences and Integrated Diagnostics; IRCCS San Martino IST; University of Genoa; Genoa Italy
| | - F. KEUS
- Department of Critical Care; University of Groningen; University Medical Center Groningen; Groningen The Netherlands
| | - A. B. GUTTORMSEN
- Department of Anaesthesia and Intensive Care; Haukeland University Hospital and Clinical Institute 1 UiB; Bergen Norway
| | - A. D. MOLLER
- Department of Anaesthesia and Intensive Care; Landspitali University Hospital; Reykjavik Iceland
| | - M. H. MØLLER
- Department of Intensive Care 4131; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
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MacLaren R, Kassel LE, Kiser TH, Fish DN. Proton pump inhibitors and histamine-2 receptor antagonists in the intensive care setting: focus on therapeutic and adverse events. Expert Opin Drug Saf 2014; 14:269-80. [DOI: 10.1517/14740338.2015.986456] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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