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Palmowski L, von Busch A, Unterberg M, Bergmann L, Schmitz S, Schlüter A, Peters J, Adamzik M, Rahmel T. Timely Cessation of Proton Pump Inhibitors in Critically Ill Patients Impacts Morbidity and Mortality: A Propensity Score-Matched Cohort Study. Crit Care Med 2024; 52:190-199. [PMID: 38240505 PMCID: PMC10793775 DOI: 10.1097/ccm.0000000000006104] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
OBJECTIVE Proton pump inhibitors (PPIs) are among the drugs most commonly used in critically ill patients. Although mainly applied temporarily for stress ulcer prophylaxis, their application is frequently not terminated. Potential adverse effects of PPI treatment could impact the outcome in case of unnecessary and, therefore, avoidable long-term continuation. We tested the hypotheses that nonindicated PPI therapy continued beyond hospital discharge is associated with increased morbidity, rehospitalization rate, and mortality. DESIGN Nationwide retrospective cohort study considering critically ill patients treated on German ICUs between January, 2017, and December, 2018 with a 2-year follow-up. SETTING A total of 591,207 patient datasets of a German healthcare insurer were screened. PATIENTS We identified 11,576 ICU patients who received PPI therapy for the first time during their index ICU stay without having an indication for its continuation. INTERVENTIONS The cohort was stratified into two groups: 1) patients without further PPI therapy and 2) patients with continuation of PPI therapy beyond 8 weeks after hospital discharge. MEASUREMENTS AND MAIN RESULTS Frequency of predescribed adverse events associated with PPI therapy, 1-year rehospitalization rate, and 2-year mortality were determined. The proportion of patients with continued PPI therapy without an objectifiable indication was 41.7% (4,825 of 11,576 patients). These patients had a 27% greater risk of pneumonia (odds ratio [OR] 1.27; 95% CI, 1.15-1.39; p < 0.001) and a 17% greater risk of cardiovascular events (OR 1.17; 95% CI, 1.08-1.26; p < 0.001). Continued PPI therapy was associated with a 34% greater risk of rehospitalization (OR 1.34; 95% CI, 1.23-1.47) and a nearly 20% greater 2-year mortality risk (hazard ratio 1.17; 95% CI, 1.08-1.27; p = 0.006). CONCLUSIONS These data demonstrate that an unnecessary continuation of PPI therapy after hospital discharge may significantly impact morbidity and mortality. To avoid potentially harmful overuse of a PPIs, intensivists should ensure timely cessation of a temporarily indicated PPI therapy.
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Affiliation(s)
- Lars Palmowski
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Alexander von Busch
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Matthias Unterberg
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Lars Bergmann
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Stefanie Schmitz
- Abteilung I - Kranken und Pflegeversicherung, Knappschaft, Bochum, Germany
| | - Andreas Schlüter
- Hauptverwaltung, Knappschaft Kliniken GmbH, Recklinghausen, Germany
| | | | - Michael Adamzik
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Tim Rahmel
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
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Han F, Zhang C, Li T, Song Z, Xu S. Impact of a multifaceted intervention on non-guideline-recommended prescribing of acid suppressive medications for stress ulcer prophylaxis in critically ill patients. Curr Med Res Opin 2023; 39:1077-1084. [PMID: 37409359 DOI: 10.1080/03007995.2023.2233826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/04/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE To promote an effective strategy to improve the non-guideline-recommended prescribing (NGRP) of acid suppressive medications for stress ulcer prophylaxis (SUP) in critically ill patients and to evaluate the impact and barriers of a multifaceted intervention on NGRP in critically ill patients. RESEARCH DESIGN AND METHODS A retrospective, pre- post-intervention study was performed in the medical-surgical ICU. This study included pre-intervention and post-intervention period. There was no SUP guideline and intervention in the pre-intervention period. In the post-intervention period, the multifaceted intervention included five features: a practice guideline, an education campaign, medication review and recommendations, medication reconciliation, and pharmacist rounding with the ICU team. RESULTS A total of 557 patients were studied (305 in the pre-intervention group and 252 in the post-intervention group). Patients who underwent surgery, stayed in ICU more than 7 days, or used corticosteroids experienced significantly higher rate of NGRP in the pre-intervention group. The average percentage of patient days of NGRP was significantly reduced from 44.2% to 23.5% (p < .001) by implementing the multifaceted intervention. The percentage of patients with NGRP decreased from 86.7% to 45.5% in terms of all 5 criteria (indication, dosage, IV to PO, duration, and ICU discharge; p = .003). Per-patient NGRP cost decreased from $45.1 (22.6, 93.0) to $11.3 (11.3, 45.1; p = .004). The main barrier influencing NGRP was the factors of the patient, including the concurrent use of nonsteroidal anti-inflammatory drugs (NSAIDs), the number of comorbidities, and undergoing surgery. CONCLUSION The multifaceted intervention was effective in improving NGRP. Further studies are needed to confirm whether our strategy is cost-effective.
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Affiliation(s)
- Furong Han
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Chao Zhang
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Tong Li
- Intensive Care Unit, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Zhihui Song
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Shanshan Xu
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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Xu P, Yi Q, Wang C, Zeng L, Olsen KM, Zhao R, Jiang M, Xu T, Zhang L. Pharmacist-Led Intervention on the Inappropriate Use of Stress Ulcer Prophylaxis Pharmacotherapy in Intensive Care Units: A Systematic review. Front Pharmacol 2021; 12:741724. [PMID: 34759821 PMCID: PMC8573417 DOI: 10.3389/fphar.2021.741724] [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] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/08/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Pharmacist's direct intervention or participation in multidisciplinary management teams can improve the clinical outcome and quality of life of patients. We aimed to determine the effectiveness of pharmacist-led interventions on the inappropriate use of stress ulcer prophylaxis (SUP) pharmacotherapy in intensive care units (ICUs). Methods: A systematic review was performed for relevant studies using searched PubMed, EMBASE (Ovid), the Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL), and four Chinese databases from the establishment of databases to 12 March 2020. We conducted a descriptive analysis of participants, the intervention content and delivery, and the effects on inappropriate medication rates. Results: From 529 records, 8 studies from 9 articles were included in the systematic review. The time of appropriateness judgment and the criteria of "appropriate" varied from included studies. Pharmacist interventions mainly included clarifying indications for SUP pharmacotherapy, education and awareness campaign, reviewed patients on SUP pharmacotherapy during rounds, and adjustments of drug use. Five (62.5%) studies found a significant intervention effect during hospitalization, while 2 (25%) studies at ICU transfer and 2 (25%) studies at hospital discharge. 4 (50%) studies identified the complications related to SUP pharmacotherapy and found no significant difference. 4 (50%) studies declared the pharmacist-led interventions were associated with cost savings. Conclusion: Pharmacist-led intervention is associated with a decrease in inappropriate use of SUP pharmacotherapy during hospitalization, at ICU transferred and hospital discharged, and a lot of medical cost savings. Further research is needed to determine whether pharmacist-led intervention is cost-effective.
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Affiliation(s)
- Peipei Xu
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Qiusha Yi
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Cuitong Wang
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Linan Zeng
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Keith M Olsen
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, United States
| | - Rongsheng Zhao
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Mingyan Jiang
- Department of Pharmacy, the First Hospital of China Medical University, Shenyang, China
| | - Ting Xu
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
| | - Lingli Zhang
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
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Jensen MM, Marker S, Do HQ, Barbateskovic M, Perner A, Møller MH. Prophylactic acid suppressants in children in the intensive care unit: a systematic review with meta-analysis and trial sequential analysis. Acta Anaesthesiol Scand 2021; 65:292-301. [PMID: 33147375 DOI: 10.1111/aas.13731] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/12/2020] [Accepted: 10/22/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Critically ill children are at risk of stress-induced gastrointestinal ulceration. Acid suppressants are frequently used in intensive care units even though there is uncertainty about the benefits and harms. With this systematic review, we aimed to assess patient-important benefits and harms of stress ulcer prophylaxis (SUP) in children in intensive care. METHODS We conducted the review according to the PRISMA statement, the Cochrane Handbook, and GRADE, using conventional meta-analysis and trial sequential analysis (TSA). We included randomised clinical trials comparing SUP with histamine-2-receptor antagonists or proton pump inhibitors vs placebo/no prophylaxis in children admitted for intensive care. Primary outcomes were all-cause mortality and overt gastrointestinal bleeding. Secondary outcomes were serious adverse events, hospital-acquired pneumonia, Clostridium difficile enteritis, myocardial ischemia, acute kidney injury and quality of life. RESULTS We included a total of seven trials (n = 504) with eight trial comparisons. We found no statistically significant difference in all-cause mortality (relative risk (RR) 1.43, 95% confidence interval (CI) 0.86-2.37), overt gastrointestinal bleeding (RR 0.75, 95% CI 0.42-1.35) or hospital-acquired pneumonia (RR 1.18, 95% CI 0.77-1.82) between SUP vs placebo/no prophylaxis. No trials reported on remaining secondary outcomes. TSA was unable to draw firm conclusions for all outcomes and certainty of evidence for all outcomes was "very low." CONCLUSIONS We found no difference in all-cause mortality, overt gastrointestinal bleeding or hospital-acquired pneumonia in children in intensive care receiving acid suppressants compared with placebo/no prophylaxis. However, the quantity and quality of evidence was very low with no firm evidence for benefit or harm.
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Affiliation(s)
- Martine M. Jensen
- Department of Intensive Care 4131 Copenhagen University HospitalRigshospitalet Copenhagen Denmark
| | - Søren Marker
- Department of Intensive Care 4131 Copenhagen University HospitalRigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Hien Q. Do
- Department of Intensive Care 4131 Copenhagen University HospitalRigshospitalet Copenhagen Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit Centre for Clinical Intervention ResearchCopenhagen University HospitalRigshospitalet Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care 4131 Copenhagen University HospitalRigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Morten H. Møller
- Department of Intensive Care 4131 Copenhagen University HospitalRigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
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Jensen MM, Marker S, Do HQ, Perner A, Møller MH. Stress ulcer prophylaxis in critically ill children: Protocol for a systematic review. Acta Anaesthesiol Scand 2019; 63:966-972. [PMID: 30907441 DOI: 10.1111/aas.13361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 03/04/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Stress ulcer prophylaxis is the considered standard of care in many critically ill patients in the intensive care unit (ICU). Whether there is overall benefit or harm of stress ulcer prophylaxis in critically ill children is unknown. Accordingly, we aim to assess patient-important benefits and harms of stress ulcer prophylaxis versus placebo or no treatment in critically ill children in the ICU. METHODS/DESIGN We will conduct a systematic review of randomized clinical trials with meta-analysis and trial sequential analysis and assess the use of proton pump inhibitors (PPIs) or histamine-2-receptor antagonists (H2RAs) versus placebo or no prophylaxis. We will systematically search the Cochrane Library, MEDLINE, EMBASE, Science Citation Index, BIOSIS, and Epistemonikos for relevant literature. We will follow the recommendations by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The risk of systematic errors (bias) and random errors will be assessed, and the overall quality of evidence will be evaluated according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. DISCUSSION There is a need for an updated systematic review to summarize the benefits and harms of stress ulcer prophylaxis in critically ill children to inform practice and future research.
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Affiliation(s)
- Martine Marker Jensen
- Department of Intensive Care, 4131 Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Søren Marker
- Department of Intensive Care, 4131 Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Hien Quoc Do
- Department of Intensive Care, 4131 Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care, 4131 Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, 4131 Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
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Wei J, Jiang R, Li L, Kang D, Gao G, You C, Zhang J, Gao L, Huang Q, Luo D, Zhao G, Zhang H, Wang S, Wang R. Stress-related upper gastrointestinal bleeding in adult neurocritical care patients: a Chinese multicenter, retrospective study. Curr Med Res Opin 2019; 35:181-187. [PMID: 29499622 DOI: 10.1080/03007995.2018.1448261] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE China has limited data on stress-related gastrointestinal ulcers in patients admitted for neurosurgical care. This study evaluated the incidence of upper gastrointestinal bleeding (UGIB) and use of stress ulcer prophylaxis (SUP) in Chinese neurocritical care patients (Glasgow Coma Scale [GCS] score ≤10). METHODS This multicenter, retrospective study was performed from January 2015 to July 2015. Medical records of 1468 patients hospitalized during 2014 were reviewed. An estimated UGIB incidence rate of 4.4% was considered for precision of 1.3% for estimation of UGIB. The primary endpoint was evaluation of overall incidence of any overt UGIB in ≤14 days after cerebral lesion. Secondary endpoints included incidence of UGIB with or and without clinically significant complications, time to UGIB, associated risk factors and SUP used. RESULTS We analyzed 1416 patients (mean age: 53.7 ± 14.00 years; males: 62.4%) with cerebral lesions. Overall incidence rate of UGIB ≤14 days was 12.9% (95% CI: 11.2%-14.7%), 0.76% with and 12.1% without significant clinical complications. Average time and duration of bleeding were 2.9 ± 3.37 days and 4.2 ± 8.4 days, respectively. The most significant risk factors for UGIB were mechanical ventilation for >48 hours (p < .0001), UGIB history (p = .0026) and use of anticoagulants (p < .0001). Acid-suppression drugs were administered for SUP in 79.0% of the patients, whereas 40.5% received hemostatic drugs. CONCLUSIONS The rate of UGIB incidence was higher than the estimated rate in neurocritical care patients in China, suggesting the need for better management and treatment for stress-related mucosal disease in China. History of UGIB, mechanical ventilation and/or anticoagulants significantly affected UGIB. ClinicalTrials registry number: NCT02316990.
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Affiliation(s)
- Junji Wei
- a Department of Neurosurgery , Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College , Beijing , China
| | - Rongcai Jiang
- b Department of Neurosurgery , Tianjin Medical University General Hospital , Tianjin , China
| | - Lihong Li
- c Department of Neurosurgery , Tangdu Hospital of the Fourth Military Medical University , Xi'an , China
| | - Dezhi Kang
- d Department of Neurosurgery , the First Affiliated Hospital of Fujian Medical University , Fuzhou , China
| | - Guodong Gao
- c Department of Neurosurgery , Tangdu Hospital of the Fourth Military Medical University , Xi'an , China
| | - Chao You
- e Department of Neurosurgery, West China School of Medicine/West China Hospital , Sichuan University , Chengdu , China
| | - Jianmin Zhang
- f Department of Neurosurgery, the Second Affiliated Hospital of Zhejiang University School of Medicine , Hangzhou , China
| | - Liang Gao
- g Department of Neurosurgery , Shanghai Tenth People's Hospital/Tenth People's Hospital of Tongji University , Shanghai , China
| | - Qibing Huang
- h Department of Neurosurgery , Qilu Hospital of Shandong University , Jinan , China
| | - Duanwu Luo
- i Department of Neurosurgery , Xiangya Hospital Central South University , Changsha , China
| | - Gang Zhao
- j Department of Neurosurgery , the First Hospital of Jilin University , Changchun , China
| | - Hongyi Zhang
- k Department of Neurosurgery , Tangshan Gongren Hospital , Tangshan , China
| | - Shuo Wang
- l Department of Neurosurgery , Beijing Tian Tan Hospital, Capital Medical University , Beijing , China
| | - Renzhi Wang
- a Department of Neurosurgery , Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College , Beijing , China
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Barbateskovic M, Marker S, Jakobsen JC, Krag M, Granholm A, Anthon CT, Perner A, Wetterslev J, Møller MH. Stress ulcer prophylaxis in adult intensive care unit patients - a protocol for a systematic review. Acta Anaesthesiol Scand 2018; 62:744-755. [PMID: 29577238 DOI: 10.1111/aas.13109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 02/25/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND In the intensive care unit (ICU), stress ulcer prophylaxis with proton pump inhibitors or histamine-2-receptor antagonists is standard of care although gastrointestinal bleeding remains uncommon. It remains unknown whether its use is associated with benefits or harms and the quality of evidence supporting the use of stress ulcer prophylaxis has been questioned. Accordingly, the objective of this systematic review was to critically assess the evidence from randomized clinical trials on the benefits and harms of stress ulcer prophylaxis vs. placebo or no prophylaxis in adult ICU patients. METHODS We will systematically search for randomized clinical trials in major international databases. Two authors will independently screen and select trials for inclusion, extract data and assess the methodological quality using the Cochrane risk of bias tool. Any disagreement will be resolved by consensus. We will perform conventional meta-analyses using Review Manager, and STATA 15, and we will assess the risk of random errors using Trial Sequential Analysis. Also, we will assess and report the overall quality of evidence for all outcomes according to GRADE. DISCUSSION The evidence on the benefits and harms of stress ulcer prophylaxis in adult ICU patients is unclear and an updated systematic review is warranted as new trials have been published. To control risks of systematic and random errors, we will use Cochrane and GRADE methodology and Trial Sequential Analysis. Our ambition with this systematic review is to provide updated, reliable and precise data to better inform decision makers on the use of stress ulcer prophylaxis in adult ICU patients.
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Affiliation(s)
- M. Barbateskovic
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen Denmark
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - S. Marker
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - J. C. Jakobsen
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen Denmark
- Department of Cardiology; Holbaek Hospital; Holbaek Denmark
| | - M. Krag
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - A. Granholm
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - C. T. Anthon
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - A. Perner
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - J. Wetterslev
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen Denmark
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - M. H. Møller
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
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Marker S, Perner A, Wetterslev J, Barbateskovic M, Jakobsen JC, Krag M, Granholm A, Anthon CT, Møller MH. Stress ulcer prophylaxis versus placebo or no prophylaxis in adult hospitalised acutely ill patients-protocol for a systematic review with meta-analysis and trial sequential analysis. Syst Rev 2017; 6:118. [PMID: 28646925 PMCID: PMC5483291 DOI: 10.1186/s13643-017-0509-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Stress ulcer prophylaxis is considered standard of care in many critically ill patients in the intensive care unit (ICU). However, the quality of evidence supporting this has recently been questioned, and clinical equipoise exists. Whether there is overall benefit or harm of stress ulcer prophylaxis in adult hospitalised acutely ill patients is unknown. Accordingly, we aim to assess patient-important benefits and harms of stress ulcer prophylaxis versus placebo or no treatment in adult hospitalised acutely ill patients with high risk of gastrointestinal bleeding irrespective of hospital setting. METHODS/DESIGN We will conduct a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis and assess use of proton pump inhibitors (PPIs) or histamine-2-receptor antagonists (H2RAs) in any dose, formulation and duration. We will accept placebo or no prophylaxis as control interventions. The participants will be adult hospitalised acutely ill patients with high risk of gastrointestinal bleeding. We will systematically search the Cochrane Library, MEDLINE, EMBASE, Science Citation Index, BIOSIS and Epistemonikos for relevant literature. We will follow the recommendations by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. The risk of systematic errors (bias) and random errors will be assessed, and the overall quality of evidence will be evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. DISCUSSION There is a need for a high-quality systematic review to summarise the benefits and harms of stress ulcer prophylaxis in hospitalised patients to inform practice and future research. Although stress ulcer prophylaxis is used worldwide, no firm evidence for benefit or harm as compared to placebo or no treatments has been established. Critical illness is a continuum not limited to the ICU setting, which is why it is important to assess the benefits and harms of stress ulcer prophylaxis in a wider perspective than exclusively in ICU patients. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017055676.
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Affiliation(s)
- Søren Marker
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark. .,Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark.
| | - Anders Perner
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark.,Department of Cardiology, Holbaek Hospital, Holbaek, Denmark
| | - Mette Krag
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Anders Granholm
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Carl Thomas Anthon
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
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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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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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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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Prevalence and outcome of gastrointestinal bleeding and use of acid suppressants in acutely ill adult intensive care patients. Intensive Care Med 2015; 41:833-45. [PMID: 25860444 DOI: 10.1007/s00134-015-3725-1] [Citation(s) in RCA: 176] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 02/27/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE To describe the prevalence of, risk factors for, and prognostic importance of gastrointestinal (GI) bleeding and use of acid suppressants in acutely ill adult intensive care patients. METHODS We included adults without GI bleeding who were acutely admitted to the intensive care unit (ICU) during a 7-day period. The primary outcome was clinically important GI bleeding in ICU, and the analyses included estimations of baseline risk factors and potential associations with 90-day mortality. RESULTS A total of 1,034 patients in 97 ICUs in 11 countries were included. Clinically important GI bleeding occurred in 2.6 % (95 % confidence interval 1.6-3.6 %) of patients. The following variables at ICU admission were independently associated with clinically important GI bleeding: three or more co-existing diseases (odds ratio 8.9, 2.7-28.8), co-existing liver disease (7.6, 3.3-17.6), use of renal replacement therapy (6.9, 2.7-17.5), co-existing coagulopathy (5.2, 2.3-11.8), acute coagulopathy (4.2, 1.7-10.2), use of acid suppressants (3.6, 1.3-10.2) and higher organ failure score (1.4, 1.2-1.5). In ICU, 73 % (71-76 %) of patients received acid suppressants; most received proton pump inhibitors. In patients with clinically important GI bleeding, crude and adjusted odds for mortality were 3.7 (1.7-8.0) and 1.7 (0.7-4.3), respectively. CONCLUSIONS In ICU patients clinically important GI bleeding is rare, and acid suppressants are frequently used. Co-existing diseases, liver failure, coagulopathy and organ failures are the main risk factors for GI bleeding. Clinically important GI bleeding was not associated with increased adjusted 90-day mortality, which largely can be explained by severity of comorbidity, other organ failures and age.
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Bardou M, Quenot JP, Barkun A. Stress-related mucosal disease in the critically ill patient. Nat Rev Gastroenterol Hepatol 2015; 12:98-107. [PMID: 25560847 DOI: 10.1038/nrgastro.2014.235] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Bleeding from stress-related mucosal disease in critically ill patients remains an important clinical management issue. Although only a small proportion (1-6%) of patients admitted to an intensive care unit (ICU) will bleed, a substantial proportion exhibit clinical risk factors (mechanical ventilation for >48 h and a coagulopathy) that predict an increased risk of bleeding. Furthermore, upper gastrointestinal mucosal lesions can be found in 75-100% of patients in ICUs. Although uncommon, stress-ulcer bleeding is a severe complication with an estimated mortality of 40-50%, mostly from decompensating an underlying condition or multiorgan failure. Although the vast majority of patients in ICUs receive stress-ulcer prophylaxis, largely with PPIs, some controversy surrounds their efficacy and safety. Indeed, no single trial has shown that stress-ulcer prophylaxis reduces mortality. Some reports suggest that the use of PPIs increases the risk of nosocomial infections. However, several meta-analyses and cost-effectiveness studies suggest PPIs to be more clinically effective and cost-effective than histamine-2 receptor antagonists, without considerable increases in nosocomial pneumonia. To help clinicians use the most appropriate strategy for treatment of patients in the ICU, this Review presents the latest information on all aspects of stress-related mucosal disease.
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Affiliation(s)
- Marc Bardou
- Gastroenterology and Hepatology Department, CHU de Dijon, France, 14 Rue Gaffarel BP77908, 21079 Dijon Cedex, France
| | - Jean-Pierre Quenot
- Medical Intensive Care Unit, CHU de Dijon, France, 14 Rue Gaffarel BP77908, 21079 Dijon Cedex, France
| | - Alan Barkun
- Gastroenterology Department, McGill University Health Centre, Montreal General Hospital Site, Room D7-346, 1650 Cedar Avenue, Montréal, QC H3G 1A4, Canada
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