Proton pump inhibitors versus histamine-2 receptor antagonists for stress ulcer prophylaxis during extracorporeal membrane oxygenation: a propensity score-matched analysis

Associated Mortality Risk of Proton Pump Inhibitor Therapy for the Prevention of Stress Ulceration in Intensive Care Unit Patients: A Systematic Review and Meta-analysis

GOALS

The aim was to systematically evaluate risks and benefits of proton pump inhibitor (PPI) use for stress ulcer prophylaxis in the critically ill patient.

BACKGROUND

Whether PPIs increase mortality in the critically ill patient remains controversial.

STUDY

Systematic review and meta-analysis of randomized controlled trials (RCTs) and cohort studies with trial sequential analysis, Bayesian sensitivity analysis, and fragility index analysis.

RESULTS

A total of 31 studies in 78,009 critically ill adults receiving PPIs versus any comparator were included. PPI use was associated with an increased mortality risk in all studies [19.6% PPI vs. 17.5% comparator; RR: 1.10; 95% confidence interval (CI): 1.02-1.20; P =0.01], in the subgroup of RCTs (19.4% vs. 18.7%; RR: 1.05; 95% CI: 1.0-1.09, P =0.04), but not cohort studies (19.9% vs. 16.7%; RR: 1.12; 95% CI: 0.98-1.28, P =0.09). Results were maintained with a Bayesian sensitivity analysis (RR: 1.13; 95% credible interval: 1.035-1.227) and a fragility index analysis, but not sequential analysis ( P =0.16). RCTs with a higher baseline severity of illness revealed the greatest mortality risk with PPI use (32.1% PPI vs. 29.4% comparator; RR: 1.09; 95% CI: 1.04-1.14; P <0.001). PPI use reduced clinically important bleeding in RCTs (1.4% PPI vs. 2.1% comparator; RR: 0.67; 95% CI: 0.5-0.9; P =0.009) but increased bleeding in cohort studies (2.7% PPI vs. 1.2% comparator; RR: 2.05; 95% CI: 1.2-3.52; P =0.009). PPI use was not associated with a lower incidence of clinically important bleeding when compared with histamine-2 receptor antagonists (1.3% vs. 1.9%; RR: 0.59; 95% CI: 0.28-1.25, P =0.09).

CONCLUSIONS

This meta-analysis demonstrated an association between PPI use and an increased risk of mortality.

Risk Factors of paediatric Venoarterial Extracorporeal Membrane Oxygenation-Related gastrointestinal bleeding after Open Heart Surgeries

OBJECTIVE

To analyze the risk factors for gastrointestinal (GI) bleeding in congenital heart disease (CHD) patients supported with venoarterial extracorporeal membrane oxygenation (V-A ECMO) after open heart surgery.

METHODS

A retrospective analysis was performed on children with (GI group: 26 cases) and without (control group: 122 cases) GI bleeding during ECMO at Shanghai Children's Medical Center from 2017 to 2020. Clinical data were analyzed and compared between groups to search for risk factors for GI bleeding.

RESULTS

A total of 148 cases were included in the study.The overall incidence of GI bleeding was 17.6% (26/148). The in-hospital mortality rate in the GI group was 61.5% (16/26) vs. 45.9% (56/122) in the control group. Twenty-six patients suffered cardiac arrest before ECMO support. The GI bleeding incidence among extracorporeal cardiopulmonary resuscitation (ECPR) patients was 50.0% (13/26) vs. 28.7 (35/122) among non-ECPR patients, P=0.035. The activated clotting time (ACT) was 201.40 s (180.47 to 247.27) in the GI group vs. 177.63 s (167.79 to 203.13) (P = 0.050) in the control group. The lowest antithrombin level (Min AT) was 27.00±13.07% vs. 37.62±15.18 (P=0.001). The pH and lactate levels before ECMO (Pre PH and Pre Lac) were lower in the GI group than in the control group. (7.31±0.23 vs. 7.35±0.17, P=0.035 and 12.2±6.11 vs. 7.78±6.67, P=0.003). Liver function during ECMO support was statistically worse in the GI group than in the control group. Multivariate analysis showed that Pre Lac (OR = 1.106 [1.018-1.202], P=0.0016) was an independent risk factor for GI bleeding. ROC analysis of Pre Lac and GI bleeding showed an area under the curve (AUC) of 0.700 (95% CI: 0.600-0.800, P=0.002) and a cutoff value of 9.30 mmol/L (sensitivity, 73.1%; specificity, 62.7%).

CONCLUSIONS

As the first study in this field, the probability of GI bleeding and related mortality were found to be high in children supported with V-A ECMO after open heart surgery. A higher lactate level before ECMO was an independent risk factor for GI bleeding.

Are Proton Pump Inhibitors More Effective Than Histamine-2-Receptor Antagonists for Stress Ulcer Prophylaxis in Critically Ill Patients? A Systematic Review and Meta-Analysis of Cohort Studies

BACKGROUND

Histamine-2-receptor antagonists (H₂RAs) have been largely replaced by proton pump inhibitors (PPIs) for stress ulcer prophylaxis (SUP) despite the inconclusive evidence concerning comparative effectiveness.

OBJECTIVE

To compare the effectiveness of PPIs and H₂RAs on SUP in real-world setting.

METHODS

PubMed, Embase, and the Cochrane Library were searched from inception to September 19, 2021. We included cohort studies comparing PPIs with H₂RAs in critically ill adult patients and explicitly reporting the outcome of gastrointestinal (GI) bleeding or mortality. Newcastle-Ottawa Scale was used to assess potential risk of bias. We conducted a random-effects meta-analysis and only the studies with adjusted effect estimates were pooled. The Grading of Recommendations Assessment, Development, and Evaluation system was used to assess the overall quality of the evidence.

RESULTS

Thirteen cohort studies (N = 145 149) were eligible and 11 of them available for full texts were of low to moderate risk of bias. Meta-analysis of adjusted effect estimates indicated that PPIs were associated with a significantly higher risk of GI bleeding, compared with H₂RAs (8 studies, odds ratio [OR] = 1.98, 95% confidence interval [CI] = 1.30-3.01, low certainty). Post hoc pooling analysis also suggested that PPIs were associated with a slightly higher risk of mortality in comparison with H₂RAs (7 studies, OR = 1.27, 95% CI = 1.13-1.42, low certainty).

CONCLUSION AND RELEVANCE

The systematic review of cohort studies showed that PPIs were associated with higher risks of GI bleeding and mortality, although the certainty of evidence was low. Overall, we suggest not excluding H₂RAs for SUP, while further studies are essential for elucidating the risk stratification, optimal regimen, and specific duration.

Diagnosis of Suspected Small Bowel Bleeding by Capsule Endoscopy in Patients with COVID-19

The current study evaluated the application of small-bowel capsule endoscopy (SBCE) in SARS-CoV-2-infected patients with suspected small bowel bleeding. We analyzed the clinical characteristics, SBCE procedures, examination results, and treatment for cases of suspected small bowel bleeding in two patients with critical COVID-19. SBCE showed active spotting bleeding in the jejunum and ileum with no identifiable lesions in case 1, while multiple small bowel ulcers were detected in case 2. Two patients had relevant changes in their management plans and received specific treatment based on SBCE findings. In summary, SBCE proved to be a non-invasive diagnostic tool for critical COVID-19 patients with suspected small bowel bleeding.

Proton pump inhibitors versus histamine-2 receptor blockers for stress ulcer prophylaxis in patients with sepsis: a retrospective cohort study

OBJECTIVE

We aimed to compare the efficacy and risks of proton pump inhibitor (PPI) versus histamine-2 receptor blocker (H2B) use for stress ulcer prophylaxis (SUP) in critically ill patients with sepsis and risk factors for gastrointestinal bleeding (GIB).

METHODS

In this retrospective cohort study, we used the Medical Information Mart for Intensive Care III Clinical Database to identify critically ill adult patients with sepsis who had at least one risk factor for GIB and received either an H2B or PPI for ≥48 hours. Propensity score matching (PSM) was conducted to balance baseline characteristics. The primary outcome was in-hospital mortality.

RESULTS

After 1:1 PSM, 1056 patients were included in the H2B and PPI groups. The PPI group had higher in-hospital mortality (23.8% vs. 17.5%), GIB (8.9% vs. 1.6%), and pneumonia (49.6% vs. 41.6%) rates than the H2B group. After adjusting for risk factors of GIB and pneumonia, PPI use was associated with a 1.28-times increased risk of in-hospital mortality, 5.89-times increased risk of GIB, and 1.32-times increased risk of pneumonia.

CONCLUSIONS

Among critically ill adult patients with sepsis at risk for GIB, SUP with PPIs was associated with higher in-hospital mortality and higher risk of GIB and pneumonia than H2Bs.