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

OBJECTIVE

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

DESIGN

Prospective, randomized clinical trial.

METHODS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

The role of the gut in the development of multiple organ dysfunction in cardiothoracic patients

Interest in the importance of the gut after injury or operation has waxed and waned over this century. Recent studies implicate the gut in septic complications and multiple organ failure after trauma, operations including cardiothoracic procedures, starvation, and other serious illnesses. Changes in the gut in sick patients include stress ulceration, bacterial overgrowth from stress ulceration prophylaxis, mucosal atrophy, loss of barrier function, increased permeability, and bacterial translocation. Such changes in relation to multiorgan failure are reviewed, along with methods to support the gut and prevent gastrointestinal failure. Preventive measures include stress ulceration prophylaxis, selective gut decontamination, enteral feeding, and adjuvants to promote gut function such as glutamine, fiber, and growth hormone. In cardiothoracic operations, the gut may be altered by the "whole body" inflammatory processes of cardiopulmonary bypass. Gastrointestinal complications after cardiothoracic operations are related primarily to low flow states. In 5,924 patients having cardiothoracic operations at St. Louis University Hospital from 1985 to 1991, multiorgan failure developed in 128 patients, with a mortality of 78%. Significant gastrointestinal problems occurred and contributed to multiorgan failure in a number of these patients. Support of the gastrointestinal tract and the prevention of multiorgan failure are important for the cardiothoracic surgeon.