Stress ulceration: prevalence, pathology and association with adverse outcomes

Protective Effect of Pentoxifylline on the Development of Acute Gastric Mucosal Injury in a Model of LPS-Induced Sepsis

Alterations in the gastric mucosal barrier, one of whose fundamental components is phosphatidylcholine (PC), may play an important role in the pathophysiology of erosive gastritis secondary to sepsis. Pentoxifylline (PTX) has been shown to reduce tissue damage in various experimental models of sepsis. The aim of this study was to investigate the effect of PTX on gastric mucosa PC synthesis, leukocyte infiltration, arachidonic acid-related metabolites, inflammation, oxidative stress, NO, CO, and somatostatin in a rat model of LPS-induced sepsis. Rats were administered LPS (10 mg/kg b.w.) intraperitoneally. After 30 min (early treatment group) or 120 min (late treatment group) of LPS administration, they were randomly divided into two groups that were intraperitoneally administered saline (5 mL/kg; LPS + Saline group) or PTX (45 mg/kg; 5 mL/kg; LPS + PTX group). Control rats received only saline instead of LPS and/or PTX. Two hours after saline or PTX administration (total of 150 or 240 min of procedure), animals were anesthetized, and then gastric lavage, gastric mucosa and plasma samples were obtained and kept frozen until determination. LPS-induced sepsis changed the gastric mucosal barrier by reducing its phospholipid content, PGI2, and somatostatin levels, as well as increasing MPO, TXB2, LTB4, PLA2, and MDA. Alterations may be mediated, at least in part, by modifications in the production of NO, CO, and cGMP content. PTX had a beneficial effect on gastric lesions secondary to sepsis by restoring PC production.

Rates, Risk Factors, and Outcomes of Nonvariceal Upper Gastrointestinal Bleeding in Patients Hospitalized for COVID-19 in the United States

OBJECTIVE

This study aimed to investigate the incidence and predictors of non-variceal upper gastrointestinal bleeding (NVUGIB) in hospitalized patients with coronavirus disease 2019 (COVID-19), as well as the inpatient outcomes associated with this complication.

METHODS

This was an analysis of the National Inpatient Sample Database from January to December 2020. Adult COVID-19 patients were categorized into two groups based on NVUGIB development during hospitalization. Multivariate logistic analysis was performed to identify predictors and outcomes associated with NVUGIB in hospitalized COVID-19 patients in the US, after adjusting for age, sex, race, and Charlson Comorbidity Index (CCI) score, using Stata/BE 17.0.

RESULTS

Among 1 050 045 hospitalized patients, 1.87% developed NVUGIB. Asian Americans had the highest risk, followed by Native Americans, Hispanics, and African Americans, with odds ratios (ORs) of 1.70, 1.59, 1.40, and 1.14, respectively. Patients with higher CCI scores were also at greater risk (with ORs of 1.47, 2.09, and 3.45 for CCI scores of 1, 2, and 3, respectively). COVID-19 patients with NVUGIB had a higher risk of inpatient mortality (OR=3.84), acute kidney injury (OR=3.12), hypovolemic shock (OR=13.7), blood transfusion (OR=7.02), and in-hospital cardiac arrest (OR=4.02).

CONCLUSION

NVUGIB occurred in 1.87% of hospitalized COVID-19 patients and was associated with a threefold increase in mortality. Further research is necessary to identify strategies for reducing its incidence in COVID-19 patients with multiple risk factors.

Application value of neutrophil to lymphocyte ratio and platelet to lymphocyte ratio in predicting stress ulcer after acute cerebral hemorrhage surgery

OBJECTIVE

The Platelet-to-Lymphocyte Ratio (PLR) and Neutrophil-to-Lymphocyte Ratio (NLR) are established biomarkers that are associated with the severity, progression, and fatality of diseases. This study aimed to determine their predictive value for the occurrence of stress ulcers (SU) following surgery for acute cerebral hemorrhage.

METHODS

Retrospective data from 210 patients with acute cerebral hemorrhage hospitalized between June 2020 and March 2023 were analyzed. Patients were categorized into two groups based on the occurrence of SU post-surgery: the SU group (42 patients) and the non-SU group (168 patients). Clinical characteristics of both groups were compared, and a multivariate logistic regression was conducted to identify independent risk factors for SU. The study evaluated the predictive value of NLR and PLR, individually and in combination, for predicting SU using Receiver Operating Characteristic (ROC) curves.

RESULTS

We observed significant differences between the SU and non-SU groups in several parameters, including GCS score, absolute neutrophils, NLR, PLR, postoperative tracheotomy, and intracranial infection (P < 0.05). Our multivariate logistic regression analysis identified four independent risk factors for SU in patients undergoing surgery for acute cerebral hemorrhage: GCS score, NLR, PLR, and fasting blood glucose (P < 0.05). Furthermore, ROC analysis demonstrated that the combination of NLR and PLR exhibited the highest AUC, sensitivity, and specificity in predicting SU following surgery for acute cerebral hemorrhage (P < 0.001), with values of 0.864 (95 % CI: 0.776-0.953), 0.778 (95 % CI: 0.658-0.899), and 0.941 (95 % CI: 0.889-0.993) respectively.

CONCLUSION

This study highlighted the combined application of PLR and NLR as a significant predictor of SU in patients post-acute cerebral hemorrhage surgery.

Gastrointestinal bleeding following traumatic brain injury: A clinical study on predisposing factors and outcomes

Background

Traumatic brain injury (TBI) is one of the most common causes of death and disability worldwide. Stress ulcers are common in critically ill patients and can lead to life-threatening gastrointestinal bleeding (GIB). This study investigates the impact of predisposing factors on GIB and outcomes of TBI patients.

Methods

This retrospective cohort study included TBI patients admitted between February 2019 and November 2021. Patients' demographic information and clinical characteristics were collected and divided into Post-TBI GIB and No-GIB groups. During clinical follow-up, the Glasgow Outcome Score (GOS) and mortality were assessed. The correlation between predisposing factors and GIB was investigated.

Results

Out of 164 eligible patients, 66.5% were males, and the mean age was 31.38 ± 13.44 years. There was a higher rate of severe TBIs (p<0.001), intra-axial lesions (P=0.014), hypotension at admission (p<0.001), and concurrent coagulopathies (p<0.001) in the Post-TBI GIB group compared to the No-GIB group. In contrast, the Glasgow Coma Scale (GCS) level upon admission and discharge (p<0.001) and serum hemoglobin level at admission (p<0.001) were lower in the Post-TBI GIB group than in the other group. Moreover, primary GCS (P=0.017) and hypotension at admission (P=0.009), spinal injury (P=0.028), and intra-axial brain injury (P=0.018) were independently associated with GIB in TBI patients.

Conclusion

Primary GCS and hypotension at admission, spinal injury, and intra-axial brain injury are independent predictors for GIB in TBI patients. The presence of GIB in TBI patients is associated with worse neurological outcomes as assessed by GOS at approximately 18 months.

Upper gastrointestinal bleeding on veno-arterial extracorporeal membrane oxygenation support

INTRODUCTION

Patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support are at a high risk of hemorrhagic complications, including upper gastrointestinal bleeding (UGIB). The objective of this study was to evaluate the incidence and impact of this complication in V-A ECMO patients.

MATERIALS AND METHODS

A retrospective single-center study (2013-2017) was conducted on V-A ECMO patients, excluding those who died within 24 h. All patients with suspected UGIB underwent esophagogastroduodenoscopy (EGD) and were analyzed and compared to the remainder of the cohort, from the initiation of ECMO until 5 days after explantation.

RESULTS

A total of 150 V-A ECMO cases (65 after cardiac surgery and 85 due to medical etiology) were included. 90% of the patients received prophylactic proton pump inhibitor therapy and enteral nutrition. Thirty-one patients underwent EGD for suspected UGIB, with 16 confirmed cases of UGIB. The incidence was 10.7%, with a median occurrence at 10 [7-17] days. There were no significant differences in clinical or biological characteristics on the day of EGD. However, patients with UGIB had significant increases in packed red blood cells and fresh frozen plasma needs, mechanical ventilation duration and V-A ECMO duration, as well as in length of intensive care unit and hospital stays. There was no significant difference in mortality. The only independent risk factor of UGIB was a history of peptic ulcer (OR = 7.32; 95% CI [1.07-50.01], p = 0.042).

CONCLUSION

UGIB occurred in at least 1 out of 10 cases of V-A ECMO patients, with significant consequences on healthcare resources. Enteral nutrition and proton pump inhibitor prophylaxis did not appear to protect V-A ECMO patients. Further studies should assess their real benefits in these patients with high risk of hemorrhage.

Anti-inflammatory, anti-oxidant and anti-ulcer activities of aqueous lyophilizate of Markhamia lutea (Bignoniaceae)

OBJECTIVES

This work was carried out with a view to determining the antioxidant, anti-inflammatory and anti-ulcer properties of the aqueous lyophilized extract of Markhamia lutea.

METHODS

In vitro proteinases inhibition, albumin denaturation, hemolysis of red blood cells by heat, inhibition of the proton pump H+/K+ATPase, FRAP (Ferric reducing antioxidant power) and DPPH (1,1-diphenyl-2-picrylhydrazyl) assays were performed. In vivo, cold water immersion-induced ulceration and methylene blue-induced ulceration was used to determine the anti-ulcer properties of the lyophilizate (100, 200 and 300 mg/kg).

RESULTS

In vitro, the lyophilizate (400 μg/mL) significantly inhibited protein denaturation (66.65 %), hemolysis of red blood cells (56.54 %), proteinase activity (69.22 %); then the IC50 was 26.31 μg/mL on proton pump activity. It has also developed a strong ferric reducing antioxidant power (EC50=52.96 mmol FeSO4/g) as well as free radicals scavenging activity (EC50=22.38 μg/mL). In vivo, the aqueous lyophilizate (200 and 300 mg/kg) protected the gastric mucosa (70.68 and 79.00 % protection respectively) and reduced (p<0.05) acetylcholine, calcium and corticosterone concentrations. A decrease in malondialdehyde level, an increased glutathione level and an increased in catalase and SOD activities were recorded. In the methylene blue test, it significantly increased gastric fluid pH, while reducing gastric volume and improving hematological parameters in ulcer animals. In addition, the histological sections show that the aqueous lyophilizate of M. lutea protected the gastric mucosa from the deleterious effects of stress.

CONCLUSIONS

The aqueous lyophilizate of M. lutea has anti-ulcer properties thanks to its anti-inflammatory, antioxidant and anti-secretory properties.

Assessment of the appropriateness of stress ulcer prophylaxis use and its determinants among admitted surgical patients at Debre Berhan University Hakim Gizaw Hospital, Ethiopia. A hospital-based cross-sectional study

Introduction

Pharmacological stress ulcer prophylaxis (SUP) has been recommended for many years to reduce the risk of clinically significant upper gastrointestinal (GI) bleeding caused by stress ulcers (SUs). Stress-related ulcer bleeding in surgical patients significantly increases morbidity and mortality. Therefore, preventing stress-induced hemorrhage is the most appropriate measure for patients who are at increased risk. However, the inappropriate use of SUP has increased in recent years, and its use in Ethiopian surgical patients has not been well studied.

Objective

The aim of this study was to assess the appropriateness of SUP use and its determinants among admitted surgical patients at Debre Berhan University Hakim Gizaw Hospital (DBUHGH), Ethiopia.

Methods

We randomly selected 230 patients from the whole cross-sectional group of all surgical patients at DBUHGH from 1 February to 30 June 2023. The risk of stress ulcer (SU) development was assessed using the modified American Society of Health-System Pharmacists (ASHP) guidelines. For data analysis, we used SPSS version 25.

Results

The mean age of study participants was 47.2 years (SD ± 20.4), and out of the total of 230, 130 (56.5%) were women. Approximately 66% of study participants took inappropriate SUP based on ASHP guidelines criteria. The most commonly used drug class for SUP was histamine-2 receptor blockers 115 (50%). Study participants who have a Charlson Comorbidity Index Score of moderate and GI bleeding have been significantly associated with the inappropriate use of SUP.

Conclusion

In our study, inappropriate SUP use was common in the surgical ward of DBUHGH. This may be an area that requires further and more focused working together among clinical pharmacists and medical professionals in an institution-specific SUP protocol that aids clinicians in identifying appropriate candidates for SUP medication.

Timely Cessation of Proton Pump Inhibitors in Critically Ill Patients Impacts Morbidity and Mortality: A Propensity Score-Matched Cohort Study

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.

Incidence of Acute Upper Gastrointestinal Bleeding and Related Risk Factors among Elderly Patients Undergoing Surgery for Major Limb Fractures: An Analytical Cohort Study

(1) Background: Upper gastrointestinal bleeding (UGIB), a major postoperative complication after surgical fixation of major limb fractures, can be fatal but is often neglected. This study determined the incidence rates of and related risk factors for perioperative UGIB among older patients with major upper limb fractures but without a history of peptic ulcer disease (PUD). (2) Methods: We collected the data of patients aged more than 65 years who underwent surgery for major limb fracture between 1 January 2001 and 31 December 2017, from Taiwan's National Health Insurance Research Database and excluded those with a history of UGIB and PUD before the date of surgery. The primary outcome was the incidence of UGIB requiring panendoscopy during hospitalization. A multiple logistic regression model was used to identify the independent predictors of UGIB, with adjustment for confounding factors. The final model included variables that were either statistically significant in univariate analyses or deemed clinically important. (3) Results: The incidence of UGIB was 2.8% among patients with major limb fractures. Male sex, older age, major lower limb fracture, and a history of chronic renal disease were significant risk factors for the increased incidence of perioperative UGIB. (4) Conclusions: Patients with major limb fractures who underwent surgery exhibited a higher rate of stress ulceration with UGIB, even when they had no history of PUD. Perioperative preventive protocols (e.g., protocols for the administration of proton-pump inhibitors) may be necessary for patients with these major risk factors.

Atypical fundal perforation: a case report

Gastric perforations typically occur in the distal stomach, along the greater curvature or the antrum. The vast majority of upper gastrointestinal (GI) perforations are caused by peptic ulcer disease. We present a case of an atypical location of gastric perforation. A 31-year-old patient was experiencing nausea and severe abdominal pain. Explorative laparoscopy revealed a large fundal perforation. The patient underwent an abdominoplasty 5 days before with revisional surgery for hemorrhage. He had recently lost 42 kg after endoscopic sleeve gastroplasty (ESG) 8 months before. ESG is a minimally invasive alternative for bariatric surgery. Since its implementation, several studies have been published indicating the procedure as safe. However, some major adverse events, such as upper GI-bleeding, peri-gastric leak, and pneumoperitoneum, have been described. The atypical location of the perforation might be explained by a combination of events such as surgical stress, revisional surgery, major weight loss, and the history of ESG.

Adverse effects of non-intubated airway suctioning: a clinical data-based study

AIMS AND OBJECTIVES

The purpose of this study was to investigate the adverse effects of non-intubated suctioning.

BACKGROUND

Airway hygiene aims to maintain a patent airway to ensure adequate ventilation. Nasopharyngeal, oropharyngeal or nasotracheal suctioning may be used in patients who require airway suctioning but do not have an artificial airway. However, no studies till date provide insight into the adverse effects of non-intubated airway suctioning.

DESIGN

A clinical data-based retrospective design.

METHOD

Using institutional and clinical databases of three university hospitals in 2008-2016, we conducted a study with a propensity score matching method of 3,326 hospitalised patients who had undergone suction therapy with or without a tracheotomy. Conditional logistic regression analyses were performed to investigate the link between suctioning and the probabilities of adverse effects. STROBE checklist was used to report the current study.

RESULTS

Patients who required nasopharyngeal, oropharyngeal or nasotracheal suctioning had a higher risk of gastrointestinal ulcers than tracheotomised patients (adjusted OR 1.99; 95% CI, 1.24-3.20). Patients who received non-intubated suction had a higher risk of developing pneumonia (adjusted OR 1.59; 95% CI, 1.26-2.00), and the risk of aspiration pneumonia was three times higher than tracheotomised patients (adjusted OR 3.04; 95% CI, 1.40-6.60).

CONCLUSIONS

Non-intubated patients who require suctioning for airway clearing are more susceptible to gastrointestinal ulcers, pneumonia and aspiration pneumonia. The findings would facilitate in alerting healthcare professionals to this group of patients. However, more clinical research is needed to elucidate the mechanisms of adverse effects in non-intubated patients who require suctioning.

RELEVANCE TO CLINICAL PRACTICE

The adverse effects of suctioning can easily be overlooked in debilitated patients with no intubation. Professionals must be aware of the discomfort and risks that patients may experience.

The role of peripheral serotonin and norepinephrine in the gastroprotective effect against stress of duloxetine

Duloxetine has been shown to produce gastroprotective effect against gastric ulcer induced by water immersion restraint stress (WIRS) via modulation of NADPH oxidases in the gastric mucosa and neurometabolites of central nucleus of amygdala. However, the underlying mechanism based on the basic pharmacological function of duloxetine-regulation on serotonin (5-HT) and norepinephrine (NE) remains unclear. Here, we found that 5-HT level in platelet-poor plasma (PPP) was decreased but NE level in plasma was increased in rats exposed to WIRS, while pretreatment with duloxetine increased 5-HT in PPP dose-dependently and decreased NE in plasma of rats after WIRS. We further showed that depletion of 5-HT by 4-chloro-DL-phenylalanine (PCPA) aggravated gastric mucosa damage and supplement of 5-HT alleviated gastric ulcers induced by WIRS. Blockade of NE receptors also mitigated the stress gastric ulcers. Using adrenalectomy and chemical blocking, we identified that it was NE from adrenal medulla rather than sympathetic nerve that was more critical in the gastroprotection of duloxetine, and intriguingly, glucocorticoid did not make a difference in WIRS-provoked gastric ulcers as a classic stress hormone. Together, our work demonstrated prophylactic protection of duloxetine from the stress gastric ulcer depended on enhancing peripheral 5-HT content and reducing NE from adrenal medulla, which provided insight into treatments of WIRS-induced gastric ulcer.

Proton Pump Inhibitor Use and Associated Infectious Complications in the PICU: Propensity Score Matching Analysis

OBJECTIVES

We aimed to evaluate the association between proton pump inhibitor (PPI) exposure and nosocomial infection (NI) during PICU stay.

DESIGN

Propensity score matched analysis of a single-center retrospective cohort from January 1, 2017, to December 31, 2018.

SETTING

Tertiary medical and surgical PICU in France.

PATIENTS

Patients younger than 18 years old, admitted to the PICU with a stay greater than 48 hours.

INTERVENTION

Patients were retrospectively allocated into two groups and compared depending on whether they received a PPI or not.

MEASUREMENTS AND MAIN RESULTS

Seven-hundred fifty-four patients were included of which 231 received a PPI (31%). PPIs were mostly used for stress ulcer prophylaxis (174/231; 75%), but upper gastrointestinal bleed risk factors were rarely present (18%). In the unadjusted analyses, the rate of NI was 8% in the PPI exposed group versus 2% in the nonexposed group. After propensity score matching ( n = 184 per group), we failed to identify an association between PPI exposure and greater odds of NI (adjusted odds ratio 2.9 [95% CI, 0.9-9.3]; p = 0.082). However, these data have not excluded the possibility that there is up to nine-fold greater odds of NI.

CONCLUSIONS

This study highlights the prevalent use of PPIs in the PICU, and the potential association between PPIs and nine-fold greater odds of NI is not excluded.

Effect of electroacupuncture on the repair of stress ulcer injury in neurocritical patients: A randomized clinical trial

BACKGROUND

Stress ulcer (SU) is one of the main causes of prolonged hospital stay, poor prognosis, and increased mortality in critically ill patients. This study aimed to investigate the effect of electroacupuncture (EA) on SU in patients with severe neurological diseases and explore its possible mechanisms.

METHODS

Taking patients with SU in adult neurocritical care as the research object, they were randomly divided into the EA group and the control group. Through the perioperative EA intervention, the following indicators were documented: main observation indicator (the effective rate of SU treatment), secondary observation indicators (gastric juice pH, gastric juice occult blood test, and stool occult blood test), related mechanisms [repair factors trefoil factor family 2 (TFF2), vascular endothelial growth factor (VEGF), and heat shock protein 70 (HSP70)], complications during hospitalization, and intensive care unit (ICU) stay time.

RESULTS

Compared with the control treatment, EA increased the effective rate of SU treatment (85.4% for the EA group, 57.5% for the control group, risk difference: 27.9% (95% CI: 8.3%-45.1%); P < 0.01). EA increased the success rate of gastric juice pH treatment on days 1, 2, and 3 (P < 0.01 for day 1, P < 0.05 for days 2 and 3). EA lowered the positive rate of gastric occult blood test on days 1 and 3 (all P-values < 0.05) and the positive rate of fecal occult blood test on day 3 (P < 0.05). EA also reduced the ICU stay time (P < 0.01) and total hospitalization time (P < 0.05). Compared with day 0, all serum repair factors (VEGF, HSP70, and TFF2) of both groups significantly increased on days 1, 3, and 5 (all P-values < 0.01). Compared with the control group, VEGF in the EA group was increased on days 3 and 5 (all P-values < 0.01); HSP70 was increased on days 1, 3, and 5 (P < 0.05 for day 1, P < 0.01 for days 3 and 5); and TFF2 was increased on days 1, 3, and 5 (all P-values < 0.01).

CONCLUSION

Electroacupuncture promoted the repair of SU damage in severe neurological disease, and its effect was related to enhancing the expression of gastric mucosal repair factors.

CLINICAL TRIAL REGISTRATION

[https://www.chictr.org.cn/showprojen.aspx?proj=127012], identifier [ChiCTR2100046701].

Emerging Trends and their Impacts on Peptic Ulcer Diseases: Treatments and Techniques

Background:

Peptic ulcer disease (PUD) is prevalent in almost all parts of the world. PUD complications are creating a major source of preventable health care expenses. The major factors responsible for the incidence of PUD and its complication have changed over the past few decades after the identification of non-steroidal inflammatory drugs (NSAIDs) and Helicobacter pylori bacterial infection along with a marked increase in the use of proton-pump inhibitors (PPIs) as drug therapy. The management of PUD has become more complex and challenging due to antimicrobial resistance.

Objective:

The objective of the study was to highlight current therapy and novel techniques used in the treatment of peptic ulcer diseases.

Methods:

An exhaustive literature search has been conducted across PubMed, Google, Scopus and Web of Science as an electronic database to add the crucial information from the relevant literature.

Results:

In the present review, we have discussed PUD and its pathophysiology. The recent trends in PUD and possible treatments with novel techniques have also been discussed. The type and presence of ulcers cannot be predicted accurately based on symptoms. The available treatment approaches for peptic ulcers based on their clinical presentation and etiology are anti-secretary therapy, endoscopy to reveal ulcers followed by drug therapy, and triple therapy for H pylori infection.

Conclusion:

Thus, the popular and effective methods are very beneficial in controlling PUD. The treatment based on diagnosis is the foremost requirement for ameliorating any disorder. In this article, the emerging techniques and development in the treatment and diagnosis of PUD have been reviewed.

Should we routinely prescribe proton pump inhibitors peri-operatively in elderly patients with hip fractures? A review of the literature

Elderly hip fracture patients are at risk of stress-related gastric mucosal damage, and upper gastrointestinal bleeding is one of the underrecognized but devastating complications.

Proton pump inhibitors (PPIs) offer effective prophylaxis against stress-related gastric mucosal damage.

Systematic analysis of the literature revealed numerous articles on PPIs and hip fractures, but only three articles dedicated to the analysis of prophylactic use of PPIs in patients with a hip fracture.

There is significant reduction in upper gastrointestinal bleeding following PPI prophylaxis and reduced 90-day mortality in elderly hip fracture patients on prophylaxis.

PPIs are generally safe, cost-effective and based on available evidence. Their prophylactic use is justifiable in elderly patients with hip fractures.

We suggest that PPIs be prescribed routinely peri-operatively in elderly hip fracture patients. Further level-one studies on the subject will allow for firmer recommendations.

Cite this article: EFORT Open Rev 2021;6:686-691. DOI: 10.1302/2058-5241.6.200053

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Acute Gastrointestinal Bleeding in COVID-19 Patients: A Systematic Review and Meta-Analysis

Background/Aims

More than 100 million people to date have been affected by the coronavirus disease-2019 (COVID-19) pandemic. Patients with COVID-19 have a higher risk of bleeding complications. We performed a systematic review and meta-analysis to evaluate the outcomes of COVID-19 patients with signs and symptoms of acute gastrointestinal bleeding (GIB).

Methods

A systematic literature search was carried out for articles published until until November 11, 2020, in the Embase, MEDLINE, Web of Science, and Cochrane Library databases. We included studies on COVID-19 patients with signs and symptoms of GIB.

Results

Our search yielded 49 studies, of which eight with a collective 127 patients (86 males and 41 females) met our inclusion criteria. Conservative management alone was performed in 59% of the patients, endoscopic evaluation in 31.5%, and interventional radiology (IR) embolization in 11%. Peptic ulcer disease was the most common endoscopic finding, diagnosed in 47.5% of the patients. Pooled overall mortality was 19.1% (95% confidence interval [CI]; 12.7%-27.6%) and pooled mortality secondary to GIB was 3.5% (95% CI; 1.3%–9.1%). The pooled risk of rebleeding was 11.3% (95% CI; 6.8%–18.4%).

Conclusions

The majority of COVID-19 patients with GIB responded to conservative management, with a low mortality rate associated with GIB and the risk of rebleeding. Thus, we suggest limiting endoscopic and IR interventions to those with hemodynamic instability and those for whom conservative management was unsuccessful.

Massive gastrointestinal bleeding in a patient with COVID-19

Despite the emerging data about the thrombophilic effect of the novel coronavirus [1] , the relation between coagulation disorders and the COVID-19 pandemic is still not well understood. Various studies pointed to the significant role of the COVID-19 induced cytokine storm in development of the hypercoagulable state which leads to serious thromboembolic complications [2,3] . Some studies report the development of severe immune thrombocytopenia induced by the novel coronavirus [4] . Other studies found a correlation between COVID-19 disease and the development of disseminated intravascular coagulation (DIC) [5]. Patients with severe COVID-19 disease have an increased risk for development of gastrointestinal bleeding (GI) which may be related to stress [6] , critical illness or mechanical ventilation [7] . Further studies showed the ability of the novel coronavirus to infect the epithelial cells of the GI tract [8] . Moreover, some data pointed to the ability of the virus even to infect the endothelium of blood vessels [9]. The relation between the COVID-19 pandemic and GI bleeding deserves more studies [10]. We present a case of GI bleeding in a patient with severe COVID-19 disease. We assume that COVID-19 disease can be a predominant factor for the development of DIC and GI bleeding.

Prophylactic acid suppressants in children in the intensive care unit: a systematic review with meta-analysis and trial sequential analysis

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.

Traumatic jejunal perforation associated with SARS-CoV-2 (COVID-19) infection

Several case reports have suggested that COVID-19 may increase the risk of gastrointestinal perforation. We report a case of a gastrointestinal perforation developing in a COVID-19 patient who presented due to injuries from a motor vehicle accident. On admission, the patient had elevated white blood cells, with neutrophilia and lymphopenia. Histological examination of tissue surrounding the perforation revealed extensive infiltration of lymphocytes and plasma cells into the intestinal mucosa. These findings are consistent with SARS-CoV-2 infection. However, further pathophysiological studies are needed to assess the mechanisms by which COVID-19 may damage the gastrointestinal mucosa leading to gastrointestinal perforation.

Stress Gastric Ulcers and Cytoprotective Strategies: Perspectives and Trends

Stress gastric ulceration is a clinical condition leading to morbidity/mortality and complex etiopathological factors are involved. Pharmacotherapy of such gastric mucosal lesions is not consistent and novel strategies are being explored. Targeting gastrointestinal factors have showed equivocal results and there is a possibility of involvement of extra-gastrointestinal factors. Stress is a highly interactive biological response in which the brain plays a key role. The involvement of brain substrates like the limbic system (amygdala, cortex, hippocampus) and behavioral traits has been investigated and research data has shown that the limbic brain-gut axis may be involved in the regulation of gastric mucosal integrity during stressful situations. The amygdaloid complex, its connections with other limbic structures and their neural networks act in tandem to contribute to both stress ulceration and gastroprotection. Complex neurotransmitter interactions in these areas involving biogenic amines and neuropeptides have been shown to modulate stress ulcerogenesis in experimental models. The immune system and brain-immune interactions also appear to play a decisive role in the genesis of such stress gastric lesions and the possibility of a brain-gut-immune axis has been proposed during stress gastric lesions. More recent studies have shown the involvement of oxidative stress and nitric oxide as well as their interactions during such stress gastric pathology, indicating the possible role of antioxidants and NO modulators as gastroprotective agents for stress ulceration. In view of the complex pathophysiology, multiple targets and lack of consistent therapeutic modalities, newer/alternative hypotheses are constantly emerging, which could be explored for effective treatment strategies aimed at gastric cytoprotection. Herbal agents with adaptogenic properties could be worth exploring in this regard as some of these phytopharmaceutical agents used in traditional medicine have been shown to exhibit gastric cytoprotection as part of their anti-stress profile. Further, their interactions with brain neurotransmitters and immune mechanisms and their relative safety could make them prospective leads for stress ulcer prophylaxis and treatment.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Protective Effects of Borago officinalis (Borago) on Cold Restraint Stress-Induced Gastric Ulcers in Rats: A Pilot Study

Stress is a typical body's natural defense to a generic physical or psychic change. A specific linking mechanism between ulcer onset and psycho-physical stress prolonged exposure has been reported. We decided to investigate the possible effects of Borago officinalis L. (Borago) in preventing physical (stress)-induced gastric ulcers in a rat model. Eighty male Sprague-Dawley rats were randomly divided into 16 groups, pretreated with a control solution, omeprazole (20 mg/kg), Borago methanolic extract (25, 50, 100, 250, and 500 mg/kg), Borago organic extract (50, 100, 250, and 500 mg/kg), Borago aqueous extract (5, 10, 20, 30, and 40 mg/kg), and D(-)-2-Amino-5-phosphonovaleric acid (AP5) (25 mg/kg) and kept in stressful conditions such as water immersion and restraint-induced stress ulcers. The animals were sacrificed and their stomach scored for the severity and the number of gastric ulcers. Methanolic extract (500 mg/kg) significantly reduced both ulcer parameters (^***p < 0.001 and ^**p < 0.01, respectively). Aqueous and organic extract significantly decreased severity score at 5 and 10 mg/kg (^**p < 0.01 and ^***p < 0.001, respectively), and at 250 and 500 mg/kg (^***p < 0.001), respectively, while gastric ulcers' resulted number significantly reduced only at 10 mg/kg (^*p < 0.05) and at 500 mg/kg (^**p < 0.01), respectively. On the other hand, aqueous extract significantly increased the mucosal gastric content of cAMP (^*p < 0.05) and NR2A and NR2B subunits (^*p < 0.05 and ^**p < 0.01, respectively) at 5 mg/kg. Organic extract showed also a significant cytotoxic effect at 500 and 1,000 mg/kg with a 3T3 cell viability reduction of 43.6% (^**p < 0.01) and 92.1% (^***p < 0.001), respectively. Borago aqueous extract at 10 mg/kg could be considered as a potential protective agent against stress-induced ulcers, and it is reasonable to possibly ascribe such protective activity to a modulation of the NR2A and NR2B subunit expression.

Gastrointestinal perforation in a critically ill patient with COVID-19 pneumonia

Gastrointestinal complications in critically ill patients during the COVID-19 pandemic pose a diagnostic and treatment dilemma. We present a case of a 74-year-old male who was brought to our emergency department with worsening shortness of breath, fever, and dry cough and was found to have COVID-19 pneumonia. Early in his hospital course, he was admitted to the intensive care unit, and was found to have significant abdominal distension with large amounts of simple fluid on bedside ultrasound. Bedside paracentesis returned succus and enteric feeds, and a methylene blue test confirmed a likely gastrointestinal perforation. The patients’ family refused surgical intervention and the patient underwent bedside drainage. This case represents several critical dilemmas clinicians faced during the recent surge of the COVID-19 pandemic.

Adherence to a stress ulcer prophylaxis protocol by critically ill patients: a prospective cohort study

OBJECTIVE

To evaluate adherence to the stress ulcer prophylaxis protocol in critically ill patients at a tertiary university hospital.

METHODS

In this prospective cohort study, we included all adult patients admitted to the medical and surgical intensive care units of an academic tertiary hospital. Our sole exclusion criterion was upper gastrointestinal bleeding at intensive care unit admission. We collected baseline variables and stress ulcer prophylaxis indications according to the institutional protocol and use of prophylaxis. Our primary outcome was adherence to the stress ulcer prophylaxis protocol. Secondary outcomes were appropriate use of stress ulcer prophylaxis, upper gastrointestinal bleeding incidence and factors associated with appropriate use of stress ulcer prophylaxis.

RESULTS

Two hundred thirty-four patients were enrolled from July 2nd through July 31st, 2018. Patients were 52 ± 20 years old, 125 (53%) were surgical patients, and the mean SAPS 3 was 52 ± 20. In the longitudinal follow-up, 1499 patient-days were studied; 1069 patient-days had stress ulcer prophylaxis indications, and 777 patient-days contained prophylaxis use (73% stress ulcer prophylaxis protocol adherence). Of the 430 patient-days without stress ulcer prophylaxis indications, 242 involved prophylaxis (56% inappropriate stress ulcer prophylaxis use). The overall appropriate use of stress ulcer prophylaxis was 64%. Factors associated with proper stress ulcer prophylaxis prescription were mechanical ventilation OR 2.13 (95%CI 1.64 - 2.75) and coagulopathy OR 2.77 (95%CI 1.66 - 4.60). The upper gastrointestinal bleeding incidence was 12.8%.

CONCLUSION

Adherence to the stress ulcer prophylaxis protocol was low and inappropriate use of stress ulcer prophylaxis was frequent in this cohort of critically ill patients.

Audit on Practices of Stress Ulcer Prophylaxis in Intensive Care Unit Patients

Background

This audit was aimed at studying current practices regarding the use of stress ulcer prophylaxis (SUP) in the Indian critical care setup, with the background aim of raising awareness regarding the use and indications of SUP in critically ill patients.

Materials and methods

After registering the trial with the clinical trial registry, India, a structured audit questionnaire containing 26 questions pertaining to SUP was distributed through electronic media among clinicians working in the intensive care units (ICUs) across India. Responses obtained were statistically analyzed.

Results

The questionnaire was sent to 550 clinicians. Only 197 responded, of whom 91.4% were anesthesiologists, 5.6% were physicians, and 3% were intensivists. The audit revealed that 33% respondents were unaware of the existing SUP guidelines and around 32% did not have protocols for SUP in their ICU. Sixty-nine percent of respondents felt that all ICU patients must receive SUP and 44.7% opined that it should be started on ICU arrival. Almost 94% knew that early enteral feeding is protective against stress ulceration. Only 24.9% responders agreed that there must be clear indications for SUP, and most of them were unaware of all the potential side effects. Once initiated, 43.7% respondents would stop prophylaxis when no indication was left, whereas 69 respondents would stop on ICU discharge.

Conclusion

There is a lack of awareness regarding initiation, choice of agent, adverse effects as well as termination of SUP in ICU and guidelines for the same. Institutional protocols should be in place and steps need to be taken to prevent unwarranted use.

How to cite this article

Gupta D, Bhalotra AR, Singh R. Audit on Practices of Stress Ulcer Prophylaxis in Intensive Care Unit Patients. Indian J Crit Care Med 2020;24(3):160–167.

Impact of a multidisciplinary quality improvement initiative to reduce inappropriate usage of stress ulcer prophylaxis in hospitalized patients

AIMS

To promote effective methods to improve overutilization patterns of acid-suppressive therapy in hospitalized patients and to evaluate the impact of multidisciplinary team efforts to reduce inappropriate use of stress ulcer prophylaxis in low-risk patients.

METHODS

A multidisciplinary quality improvement initiative incorporating education, medication use reviews and reconciliation, and pharmaceutical intervention was implemented in June 2018 for surgical patients hospitalized via emergency department. For the pre-post analysis and time series analysis, patients admitted during April and May were classified into the pre-intervention cohort and those admitted during July and August into the post-intervention cohort.

RESULTS

Three hundred and seventeen patients were included in this study (153 and 164 in the pre- and post-intervention cohorts, respectively). The multidisciplinary program was effective in reducing overuse of stress ulcer prophylaxis and healthcare expenses associated with it. Biweekly education on risk factors warranting stress ulcer prophylaxis was provided for clinicians, and acid-suppressive therapy was removed from a preset list of admission orders. The incidence of inappropriate prophylaxis use declined substantially following intervention in overall patients (OR = 0.51, P = 0.01) and a significant decrease was primarily observed among non-ICU patients (OR = 0.50, P = 0.01). Interrupted time series analysis confirmed the significant decline in inappropriate use post intervention (coefficient = -0.63, P < 0.001). The total healthcare expenses associated with such overuse decreased by 58.5% from US$ 19.39 to US$ 8.04 per 100 patient-days.

CONCLUSIONS

Our multidisciplinary team efforts were associated with improvement in stress ulcer prophylaxis overuse patterns, resulting in a substantial decrease in the incidence of inappropriate use, especially in general wards, and associated healthcare costs.

Stress ulcer prophylaxis with proton pump inhibitors or histamine 2 receptor antagonists in critically ill adults - a meta-analysis of randomized controlled trials with trial sequential analysis

Background

Proton pump inhibitors (PPI) and histamine 2 receptor antagonists (H2RA) have been widely used as stress ulcer prophylaxis (SUP) in critically ill patients, however, its efficacy and safety remain unclear. This study aimed to assess the effect of SUP on clinical outcomes in critically ill adults.

Methods

Literature search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane database of clinical trials for randomized controlled trials (RCTs) that investigated SUP, with PPI or H2RA, versus placebo or no prophylaxis in critically ill patients from database inception through 1 June 2019. Study selection, data extraction and quality assessment were performed in duplicate. The primary outcomes were clinically important gastrointestinal (GI) bleeding and overt GI bleeding. Conventional meta-analysis with random-effects model and trial sequential analysis (TSA) were performed.

Results

Twenty-nine RCTs were identified, of which four RCTs were judged as low risk of bias. Overall, SUP could reduce the incident of clinically important GI bleeding [relative risk (RR) = 0.58; 95% confidence intervals (CI): 0.42–0.81] and overt GI bleeding (RR = 0.48; 95% CI: 0.36–0.63), these results were confirmed by the sub-analysis of trials with low risk of bias, TSA indicated a firm evidence on its beneficial effects on the overt GI bleeding (TSA-adjusted CI: 0.31–0.75), but lack of sufficient evidence on the clinically important GI bleeding (TSA-adjusted CI: 0.23–1.51). Among patients who received enteral nutrition (EN), SUP was associated with a decreased risk of clinically important GI bleeding (RR = 0.61; 95% CI: 0.44–0.85; TSA-adjusted CI: 0.16–2.38) and overt GI bleeding (RR = 0.64; 95% CI: 0.42–0.96; TSA-adjusted CI: 0.12–3.35), but these benefits disappeared after adjustment with TSA. Among patients who did not receive EN, SUP had only benefits in reducing the risk of overt GI bleeding (RR = 0.37; 95% CI: 0.25–0.55; TSA-adjusted CI: 0.22–0.63), but not the clinically important GI bleeding (RR = 0.27; 95% CI: 0.04–2.09).

Conclusions

SUP has benefits on the overt GI bleeding in critically ill patients who did not receive EN, however, its benefits on clinically important GI bleeding still needs more evidence to confirm.

Clinical and economic benefits of de-escalating stress ulcer prophylaxis therapy in the intensive care unit: A quality improvement study

Stress ulcer prophylaxis is commonly prescribed in the intensive care unit but can be inappropriately commenced or continued on discharge, exposing patients to potential harm. We aimed to evaluate whether a prescribing guideline, education program and pharmacist oversight would reduce inappropriate continuation of stress ulcer prophylaxis. This was a multicentre pre- (2014) and post- (2016) quality improvement study across five Australian intensive care units. Cost data were estimated using local information about prescribing patterns, and the relationship between long-term use and adverse events. A total of 531 patients were included in the pre- and 393 in the post-implementation periods. The proportion of hospital survivors inappropriately continued on stress ulcer prophylaxis reduced from 78/184 (42.4%) to 11/143 (7.7%) in the post-implementation period (odds ratio = 8.83; 95% confidence interval 4.47–17.45; P < 0.0001). Clostridium difficile–associated disease reduced from 10 patients to one in the pre- to post-implementation groups. The extrapolated direct savings to all Australian intensive care units from reduced proton pump inhibitor prescribing are relatively small (AUD$2.08 million/year), but the reduction in complications has both benefits for patients and indirect savings of AUD$16.59 million/year nationally. In patients admitted to the intensive care unit, the introduction of a simple, bundled intervention resulted in a significant decrease in inappropriate continuation of stress ulcer prophylaxis at hospital discharge and a reduction in recognised complications, and substantial cost savings.

The effect of systemic corticosteroids on the incidence of gastrointestinal bleeding in critically ill adults: a systematic review with meta-analysis

PURPOSE

To assess the effect of systemic corticosteroids on the incidence of gastrointestinal bleeding in adult critically ill patients.

METHODS

We systematically reviewed randomised clinical trials comparing systemic corticosteroids administered for more than 24 h with placebo/no treatment in adult critically ill patients. Trial selection, data abstraction and risk of bias assessments were performed in duplicate. We used trial sequential analysis (TSA) to assess the risk of random errors and the grading of recommendations, assessment, development, and evaluations (GRADE) approach to assess the quality of evidence. The primary outcome was the incidence of clinically important gastrointestinal bleeding within 90 days. The secondary outcome was the incidence of gastrointestinal bleeding of any severity within 90 days.

RESULTS

Twenty-five trials (n = 14,615) reported data for the primary outcome and 55 trials (n = 21,792) for the secondary outcome. The pooled incidence of clinically important gastrointestinal bleeding was 2.3% in the corticosteroid group and 1.8% in the control group (RR, 1.26; 95% CI, 1.01-1.57; I² = 0%, TSA-adjusted CI 0.51-3.14). We observed no difference in the risk of gastrointestinal bleeding of any severity (RR, 1.10; 95% CI, 0.92-1.32; I² = 0%, TSA-adjusted CI 0.87-1.38). The GRADE quality of evidence was low (risk of bias and imprecision).

CONCLUSIONS

We observed an overall low incidence of clinically important gastrointestinal bleeding among adult critically ill patients. Corticosteroids may slightly increase the incidence of clinically important gastrointestinal bleeding, but not bleeding of any severity. Rarity of events, infrequent trial reporting and high risk of bias reduced the quality of evidence.

Stress ulcer prophylaxis in critically ill children: Protocol for a systematic review

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.

Stress-related upper gastrointestinal bleeding in adult neurocritical care patients: a Chinese multicenter, retrospective study

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.

Acid Suppression to Prevent Gastrointestinal Bleeding in Patients With Ventricular Assist Devices

BACKGROUND

The high incidence of gastrointestinal bleeding (GIB) in patients with ventricular assist devices (VAD) is well known, but there is limited evidence to support the use of proton pump inhibitors (PPIs) or histamine receptor antagonists (H2RA) for preventing GIB in patients with VAD.

MATERIALS AND METHODS

The surgical ICU and VAD databases within a large regional academic cardiac mechanical support and transplant center were queried for patients who underwent VAD implantation between 2010 and 2014. An observational cohort study was conducted to identify which acid suppressing drug regimen was associated with the fewest number of GIB events within 30 d after VAD implantation: PPI, H2RA, or neither. Secondary outcomes included timing, etiology, and location of GIB. Multivariable logistic regression was used to compare treatment cohorts to GIB. Odds ratios, 95% confidence intervals, and P-values were reported from the model.

RESULTS

One hundred thirty-eight patients were included for final analysis, 19 of which had a GIB within 30 days of VAD implantation. Both H2RA and PPI use were associated with reduced GIB compared with the cohort with no acid suppressive therapy. In the multivariate analysis, the PPI cohort showed a statistically significant reduction in GIB (Odds ratio 0.18 [95% confidence interval 0.04-0.79] P = 0.026).

CONCLUSIONS

Using PPI postoperatively in patients with new VAD was associated with a reduced incidence of GIB. Given that GIB is a known complication after VAD placement, clinicians should consider the use of acid suppressive therapy for primary prevention.

Gastrointestinal Bleeding in Patients With Acute Respiratory Distress Syndrome: A National Database Analysis

Background

The goal of our study was to determine the impact of gastrointestinal bleeding (GIB) on in-hospital outcomes among acute respiratory distress syndrome (ARDS) patients, and subsequently determine the potential risk factors for the development of GIB.

Methods

ARDS patients with and without GIB were identified using the National Inpatient Sample (2002 - 2012). Linear regression analysis was used to assess impact of GIB on in-hospital mortality, length of stay and total charges. Univariate logistic regression was used to determine associated odds ratios (OR) for causes of ARDS and common comorbid conditions.

Results

We identified 149,190 ARDS patients. The incidence of GIB was the highest among patients > 60 years (P < 0.001). GIB was associated with longer hospitalization days (7.3 days versus 11.9 days, P < 0.001), higher mortality (11% versus 27%, P < 0.001) and greater economic burden ($82,812 versus $45,951, P < 0.001). GIB was common in cirrhosis (OR: 8.3), peptic ulcer disease (OR: 3.7), coagulopathy disorders (OR: 3.003), thrombocytopenia (OR: 2.6), anemia (OR: 2.5) and atrial fibrillation (OR: 1.5). ARDS secondary to aspiration pneumonia (OR: 2.0), pancreatitis (OR: 2.0), sepsis (OR: 1.6) and community acquired pneumonia (OR: 0.8) was more likely to have GIB.

Conclusion

Our study demonstrates that GIB in ARDS patients is associated with significant increased mortality, hospitalization and health care cost.

Use of Enteral Nutrition for Gastrointestinal Bleeding Prophylaxis in the Critically Ill: Review of Current Literature

PURPOSE OF REVIEW

This review provides a comprehensive overview of the etiology of stress-related mucosal disease, current acid suppression therapy recommendations, and the role enteral nutrition may play in disease prevention.

RECENT FINDINGS

Recent literature indicates enteral nutrition may prevent complications of stress-related mucosal disease by increasing splanchnic blood flow, enhancing gastrointestinal motility, and promoting cellular immunity and integrity through local nutrient delivery. Stress-related mucosal disease is a common complication of hospitalization in the critically ill which may lead to overt gastrointestinal bleeding and enhanced mortality. High-risk patients have historically been prescribed acid suppression therapy, though enteral nutrition may also have a role in disease mitigation.

Stress ulcer prophylaxis in adult intensive care unit patients - a protocol for a systematic review

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.

Comparing efficacy of enteral nutrition plus ranitidine and enteral nutrition alone as stress ulcer prophylaxis

Aim: Adequacy of enteral nutrition (EN) alone as stress ulcer prophylaxis (SUP) is controversial. The aim of this study was to compare efficacy of EN alone and ranitidine plus EN as SUP. Method: Critically ill adults with indications to receive SUP were randomized to ranitidine 50 mg IV every 8 h plus EN (SUP) or EN alone (non-SUP) group for 7 days. Besides, endoscopy was performed at the time of recruitment and on day 7. Results: During the study period, only one patient in each group of SUP and non-SUP experienced gastrointestinal bleeding. At the time of recruitment, gastric erosion and erythema were the most endoscopic findings in the SUP and non-SUP groups. These findings did not significantly change at the end of the study (p = 0.21). Conclusion: EN was at least effective as ranitidine plus EN as SUP.

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

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.

Impact of A Collaborative Strategy to Reduce the Inappropriate Use of Acid Suppressive Therapy in Non-Intensive Care Unit Patients

BACKGROUND

Stress ulcer prophylaxis (SUP) is inappropriately prescribed in more than 30% of non-intensive care unit (ICU) patients, leading to unnecessary adverse events as well as increases in economic burden.

OBJECTIVE

There was an increasing trend in the prophylactic use of acid suppressive therapy (AST) in non-critically ill patients at our institution, which prompted this initiative aimed at reducing the inappropriate use of AST in non-ICU patients.

METHODS

This was a retrospective interventional study that consisted of formulation of a guideline, education to the hospitalist service, and intervention by clinical pharmacists. All adult non-ICU patients admitted to the hospitalist service who were newly initiated on AST were considered for inclusion. The primary outcome was a comparison of the proportion of inpatient days with inappropriate AST. Secondary outcomes included a comparison of patients discharged on inappropriate AST and drug acquisition costs, successful pharmacy interventions, hospitalist interventions, incidence of Clostridium difficile infection (CDI) or gastrointestinal (GI) bleeding, and drug costs averted through pharmacy intervention.

RESULTS

There were 61 patients in the historical group and 81 patients in the interventional group. This intervention resulted in a 31% absolute reduction in inappropriate patient days of AST and a 24% absolute reduction in patients discharged on inappropriate AST. There were 23 successful interventions. There were no cases of CDI and 1 GI bleed. This intervention resulted in an 87% reduction in drug acquisition costs per patient.

CONCLUSIONS

A collaboration between clinical pharmacists and a hospitalist service can significantly reduce the inappropriate use of AST in non-ICU patients.

Pantoprazole or Placebo for Stress Ulcer Prophylaxis (POP-UP): Randomized Double-Blind Exploratory Study

OBJECTIVES

Pantoprazole is frequently administered to critically ill patients for prophylaxis against gastrointestinal bleeding. However, comparison to placebo has been inadequately evaluated, and pantoprazole has the potential to cause harm. Our objective was to evaluate benefit or harm associated with pantoprazole administration.

DESIGN

Prospective randomized double-blind parallel-group study.

SETTING

University-affiliated mixed medical-surgical ICU.

PATIENTS

Mechanically ventilated critically ill patients suitable for enteral nutrition.

INTERVENTIONS

We randomly assigned patients to receive either daily IV placebo or pantoprazole.

MEASUREMENTS AND MAIN RESULTS

Major outcomes were clinically significant gastrointestinal bleeding, infective ventilator-associated complication or pneumonia, and Clostridium difficile infection; minor outcomes included overt bleeding, hemoglobin concentration profiles, and mortality. None of the 214 patients randomized had an episode of clinically significant gastrointestinal bleeding, three patients met the criteria for either an infective ventilator-associated complication or pneumonia (placebo: 1 vs pantoprazole: 2), and one patient was diagnosed with Clostridium difficile infection (0 vs 1). Administration of pantoprazole was not associated with any difference in rates of overt bleeding (6 vs 3; p = 0.50) or daily hemoglobin concentrations when adjusted for transfusion rates of packed red cells (p = 0.66). Mortality was similar between groups (log-rank p = 0.33: adjusted hazard ratio for pantoprazole: 1.68 [95% CI, 0.97-2.90]; p = 0.06).

CONCLUSIONS

We found no evidence of benefit or harm with the prophylactic administration of pantoprazole to mechanically ventilated critically ill patients anticipated to receive enteral nutrition. The practice of routine administration of acid-suppressive drugs to critically ill patients for stress ulcer prophylaxis warrants further evaluation.