Stress ulcer prophylaxis in medical ICU patients: annual utilization in relation to the incidence of endoscopically proven stress ulceration

When to Feed the Patient With Gastrointestinal Bleeding

Whether to provide artificial enteral nutrition therapy to a patient with evidence of gastrointestinal bleeding (GIB) creates a difficult clinical dilemma. Concern that enteral feeding may contribute to the morbidity associated with GIB leads to delays in initiating enteral therapy or to cessation of feeding in the patient in whom artificial nutrition support has already been started. Surprisingly, evidence of GIB is not an automatic contraindication to further enteral feeding. Depending on the etiology of the GIB, enteral nutrition may protect the gut mucosa and reduce further bleeding in some patients, actually increase risk for rebleeding in other patients, or serve as a moot point with no relation to further bleeding or morbidity in still other patients. In many cases, an endoscopic evaluation is needed to distinguish the differential etiology of the GIB. The nutrition support specialist needs a full understanding of the physiology behind the varying diagnoses for GIB to know whether feedings can be initiated or continued or whether enteral feedings need to be withheld for 48-72 hours until risk for rebleeding and further morbidity is minimized.

A Review of Stress Ulcer Prophylaxis

Stress-related mucosal damage (SRMD) is an erosive process of the gastroduodenum that occurs frequently in critically ill patients. Symptomatic lesions may range from overt bleeding (by hematemesis, melena, bloody or coffee ground aspirates, or hematochezia) to clinically significant hemorrhage (hypotension, tachycardia, or acute anemia requiring transfusion). SRMD is caused by mucosal ischemia that produces an imbalance between injurious factors and the protective mechanisms. Common patient risk factors include mechanical ventilation, coagulopathy, shock, hepatic dysfunction, renal dysfunction, thermal injury, trauma, kidney or liver transplant, head injury or spinal cord injury, recent gastrointestinal hemorrhage, and pharmacologic interventions. Stress ulcer prophylaxis may be provided by administering one of the following pharmacologic agents: an antacid, a histamine2 receptor antagonist, sucralfate, or a proton pump inhibitor. All agents possess equal efficacies but differ in their mechanisms of action, adverse event profile, drug interactions, monitoring requirements, costs, and personnel requirements for preparation and administration. Implementation of institution-specific protocols for stress ulcer prophylaxis provides cost minimization by maximizing appropriate drug usage.

Current Concepts in Severe Sepsis and Septic Shock

Sepsis is a frequent cause of presentation to the emergency department (ED). Early identification and aggressive management in the ED is paramount to improving morbidity and mortality associated with sepsis. As a result, pharmacists in the ED should be familiar with and assist with the optimization of therapy for sepsis in this patient population. This article will discuss the epidemiology and economic impact of sepsis and the definitions, pathophysiology, and clinical presentation of sepsis and its related syndromes. In addition, the authors will discuss the elements related to treatment of sepsis from the Surviving Sepsis Campaign Guidelines that are particularly germane to the management of sepsis in the ED. Direct support such as source control, early broad-spectrum antibiotic therapy, hemodynamic assessment, and continuous monitoring are essential. In addition, early aggressive fluid resuscitation with titration of therapy to mixed venous oxygen saturation >70%, tight glycemic control and choice of vasopressors and inotropes have been shown to decrease mortality in sepsis. Mechanical ventilation with low tidal volumes, renal replacement therapies, early enteral nutritional support, and stress ulcer prophylaxis are also important considerations in septic patients. Controversies in therapy such as the utility of drotrecogin α activated, low-dose corticosteroids, and vasopressin are also discussed.

Proton Pump Inhibitors and the Risk for Hospital-Acquired Clostridium difficile Infection

OBJECTIVE

To examine the relationship between proton pump inhibitor (PPI) usage and nosocomial Clostridium difficile infection (CDI) and determine the duration of therapy at which CDI risk increases.

PATIENTS AND METHODS

This retrospective case-control study included consecutive adult patients in whom nosocomial CDI developed after hospitalization for 3 or more days at one of 2 affiliated hospitals between June 1, 2010, and October 31, 2011. These patients were matched to patients hospitalized within 6 months who did not have CDI development in a 1:2 ratio using age, sex, and antibiotic usage. Potential risk factors for CDI, including PPI use and duration, were evaluated. Multivariate analysis was performed to control for confounding variables and identify risk factors.

RESULTS

A total of 201 patients were evaluated, 67 with CDI and 134 matched controls. Patients in whom CDI developed were more likely to have received a PPI (76% vs 39%; P<.001) and had a longer duration of PPI therapy (median [range], 5 [0-20] days vs 0 [0-11] days; P<.001) than those who did not have CDI development. After controlling for prior hospital admission, intensive care unit admission, admission from a skilled nursing facility, immunosuppression, number of antibiotics received, PPI duration, and time to event via multivariate analysis, PPI duration was found to be a risk factor for CDI (odds ratio, 1.14; 95% CI, 1.02-1.27; P=.018). The probability for CDI was higher when PPI use exceeded 2 days in patients without a prior hospital admission and 1 day in patients with a prior admission.

CONCLUSION

The duration of PPI therapy is significantly associated with CDI. Clinicians should strongly consider restricting PPI use given the short exposure time associated with this increased risk.

Deep Vein Thrombosis and Stress Ulcer Prophylaxis in the Intensive Care Unit

Deep vein thrombosis (DVT) and stress gastric ulcers can be serious complications in patients admitted to the intensive care unit. This review discusses the risk factors associated with the development of DVT and stress-related mucosal disease (SRMD), evaluates the available literature on current options for DVT and stress ulcer prophylaxis, and examines the associated adverse effects and optimal duration of therapy.

Ranitidine is unable to maintain gastric pH levels above 4 in septic patients

PURPOSE

The study aimed to evaluate whether ranitidine and pantoprazole are able to maintain gastric pH >or=4 in septic patients.

MATERIALS AND METHODS

Twenty intensive care unit patients from a university teaching hospital with sepsis were included in this study. Ten patients received ranitidine (50 mg as an intermittent bolus 3 times a day) and 10 received pantoprazole (40 mg as an intermittent bolus twice a day). Gastric pH was measured continuously for 48 hours. Endoscopy of the upper digestive tract, gastric biopsy, and investigation for Helicobacter pylori were carried out before and at the end of the study.

RESULTS

pH values >or=4 were maintained for 46.27% +/- 38.21% and 81.57% +/- 19.65% of study time in the ranitidine and pantoprazole groups, respectively (P = .04).

CONCLUSIONS

Intravenous ranitidine was unable to maintain gastric pH above 4 in septic patients. All cases in the ranitidine group in whom pH remained above 4 had gastric hypotrophy or atrophy. Pantoprazole successfully maintained pH levels above 4.

Famotidine Versus Pantoprazole for Preventing Bleeding in the Upper Gastrointestinal Tract of Critically Ill Patients Receiving Mechanical Ventilation

Background Mechanical ventilation increases risk for bleeding in the upper part of the gastrointestinal tract. Proton pump inhibitors, although they are more potent and longer acting inhibitors of gastric acid production than are histamine2 antagonists, also are generally more expensive. Data comparing the 2 types of agents for preventing gastrointestinal bleeding in critically ill patients are limited.

Objectives To compare the effectiveness of famotidine (a histamine2 antagonist) and pantoprazole (a proton pump inhibitor) in preventing stress ulcers in critically ill patients receiving mechanical ventilation.

Methods Data were collected from the Project Impact database. All patients who received mechanical ventilation for more than 48 hours from November 2002 to June 2006 and were treated with either drug were included. Patients receiving other drugs or with known bleeding in the upper part of the gastrointestinal tract, thrombocytopenia, or coagulopathy were excluded.

Results A total of 522 patients who received famotidine and 95 who received pantoprazole were included. Bleeding in the upper part of the gastrointestinal tract was more common in patients receiving pantoprazole than in patients receiving famotidine (0.38% vs 3.2%, P= .03). Although scores on the Acute Physiology and Chronic Health Evaluation II were higher in patients who received pantoprazole (P= .01), other outcome measures did not differ significantly between groups. Bleeding in the upper part of the gastrointestinal tract was more frequent among dialysis patients receiving pantoprazole than among those receiving famotidine.

Conclusions Famotidine and pantoprazole are similarly effective for preventing bleeding in the upper part of the gastrointestinal tract in patients receiving mechanical ventilation.

Stress ulcer prophylaxis for non-critically ill patients on a teaching service

RATIONALE

Doctors frequently give non-critically ill patients unjustified stress ulcer prophylaxis (SUP). It is unknown if this practice also occurs during residency training.

OBJECTIVE

To evaluate the pattern of SUP given to non-critically ill medical patients on the teaching service of an internal medicine residency programme.

METHODS

This was a retrospective cohort study of non-critically ill adults admitted to the internal medicine teaching service of a community hospital from August 2003 to July 2004. We assessed receipt of SUP, association of SUP with risk factors for stress ulcer bleeding; appropriateness of SUP according to evidence-based criteria; and incidence of stress ulcer bleeding.

RESULTS

Of the 774 patient records reviewed, 545 were included in the study. The average age was 55.4 years. Patients were more likely to receive SUP if they had more risk factors for stress ulcer bleeding (P < 0.001). Overall, 54.9% (299 of 545) of patients received SUP. Of these 299 patients, at least 58.5% did not warrant SUP, depending on the criteria used. Of the entire cohort of 545 non-critically ill patients, 32.1% to 54.9% received unjustified SUP, depending on the criteria applied. There were no cases of stress ulcer bleeding.

CONCLUSIONS

Many non-critically ill patients on the teaching service received unjustified SUP, suggesting the need for institutional protocols and educational interventions to promote evidence-based practice during residency training.

Sialyl Lewis X analog attenuates gastric microcirculatory disturbance and gastric mucosal erosion induced by thermal injury in rats

BACKGROUND AND AIM

We hypothesize that selectins, which are adhesion molecules, are involved in the pathogenesis of stress-induced gastropathy. We therefore investigated whether the novel Sialyl Lewis X (SLex) analog, which is a clinically available antagonist of selectins, attenuate gastric mucosal lesions induced by thermal injury.

METHODS

Male Wistar rats were anesthetized and a 30% full-skin thickness dorsal burn was inflicted on each rat. The SLex analog was administrated into the jugular vein 30 min before and 2.5 h after the thermal injury. Saline was administered to the vehicle group. The distribution of E-selectin immunoreactivity on the luminal side of the gastric mucosal microvascular network was observed by immunohistochemical methods. Active oxygen species were measured by the chemiluminescence method. Rolling leukocytes and endothelial damage, investigated by using Monastral Blue B (MBB), of the gastric mucosal microvascular network were observed through an intravital microscope.

RESULTS

A high intensity of E-selectin fluorescence was observed on the luminal surface of the venular endothelial cells 5 h after thermal injury in the vehicle group. However, E-selectin-associated fluorescence was almost negligible in the non-injury group and in the SLex analog group. The SLex analog also attenuated the rolling of leukocytes in the venules, venular deposits of MBB, luminol-dependent chemiluminescence activities, and gastric mucosal lesion formation.

CONCLUSION

It is suggested that the selectin family is involved in gastric microcirculatory disturbance and the pathogenesis of gastric mucosal lesions after thermal injury. A novel preventive therapy using the SLex analog is considered to effectively protect both gastric microcirculation and the gastric mucosa in rats with thermal injury.

Use of enteral nutrition for stress ulcer prophylaxis

OBJECTIVE

To review the controversies involving the use of enteral nutrition support for stress ulcer prophylaxis and formulate recommendations.

DATA SOURCES

A MEDLINE search (1966-December 2000) was conducted using the MeSH of nutrition, ulcer, critical care, and acid to identify relevant articles. References of selected articles were reviewed, and relevant abstracts from critical care or gastrointestinal journals identified.

DATA EXTRACTION

Animal and human data from prospective studies, retrospective studies, and case series were evaluated for the effects of enteral nutrition on gastric pH, intramucosal pH, gastrointestinal blood flow, development of macroscopic mucosal erosions, and hemorrhage.

DATA SYNTHESIS

Intragastric administration of enteral nutrition has variable effects on gastric pH, enhances regional distribution of gastrointestinal blood flow, and may lower intramucosal pH. All substrates (carbohydrate, lipid, amino acid), when administered into the stomach, reduce the occurrence of mucosal erosions but do not entirely prevent their development. Few studies of stress ulcer prophylaxis regimens have reported use of enteral nutrition. Limited retrospective data suggest enteral nutrition support may be effective for preventing gastrointestinal hemorrhage, but the results of prospective studies are confounded by poor study design.

CONCLUSIONS

Definitive recommendations regarding the role of enteral nutrition for stress ulcer prophylaxis are not possible due to the lack of prospective, randomized studies. Therefore, the use of enteral nutrition as the only therapeutic agent for stress ulcer prophylaxis should be discouraged until definitive data are available. Initiation and discontinuation of pharmacologic stress ulcer prophylaxis should be independent of enteral nutrition.

Role of acid suppressants in intensive care medicine

Bleeding from stress-induced mucosal lesions continues to be a potential problem in critically ill patients, although its incidence has decreased dramatically over the past decade. Patients considered to be at risk are those with respiratory failure, coagulopathy, severe burns or tetraplegia. The most important cause of stress ulcer bleeding is tissue hypoxia. Provided that appropriate dosage regimens are administered, all agents approved for stress ulcer prophylaxis may reduce the incidence of overt as well as clinically important bleeding. However, the efficacy of stress ulcer prophylaxis does not correlate with the efficacy of gastric acid inhibition. Although numerous studies have demonstrated that an alkaline gastric juice is associated with gastric Gram-negative bacterial overgrowth, controversy remains over whether the pharmacological suppression of gastric acid in critically ill patients facilitates nosocomial pneumonia. The reasons for these divergent results are discussed, as is a possible association between gastric acid suppression and other systemic infections. Finally, several cost-effectiveness analyses performed over recent years have demonstrated that, in properly selected critically ill patients, stress ulcer prophylaxis is cost-effective.

Reduced gastric acid production in burn shock period and its significance in the prevention and treatment of acute gastric mucosal lesions

AIM: To investigate the changes of gastric acid production and its mechanism in shock period of severe burn in rats.

METHODS: A rat model with 30% TBSA full-thickness burn injury w as employed and the gastric acid production, together with gastric mucosal blood flow (GMBF) and energy charge (EC) were measured serially within 48 h postburn.

RESULTS: The gastric acid production in the acute shock period was markedly inhibited after severe burn injury. At the 3rd h postburn, the gas tricjuice volume, total acidity and acid output were already significantly decreased (P < 0.01), and reached the lowest point, 0.63 mL/L ± 0.20 mL/L, 10.81 mmol/L ± 2.58 mmol/L and 2.23 mmol/h ± 0.73 mmol/h respectively, at the 12th h postburn. Although restored to some degree 24 h after thermal injury, the variables above were still statistically lower, compared with those of control animals at the 48th h postburn. The GMBF and EC were also significantly reduced after severe burns, co nsistent with the trend of gastric acid production changes.

CONCLUSION: Gastric acid production, as well as GMBF and EC was predominantly decreased in the early postburn stage, suggesting that gastric mucosal ischemia and hypoxia with resultant disturbance in energy metabolism, but not gastric acid proper, might be the decisive factor in the pathogenesis of AGML after thermal injury, and that the preventive use of anti-acid drugs during burn shock period was unreasonable in some respects. Therefore, taking effective measures to improve gastric mucosal blood perfusion as early as possible postburn might be more preferable for the AGML prevention and treatment.

Impact of trauma stress ulcer prophylaxis guidelines on drug cost and frequency of major gastrointestinal bleeding

Trauma patients are routinely prescribed stress ulcer prophylaxis despite evidence suggesting such therapy be limited to patients with identifiable risk factors for bleeding. With surgeons' consensus, we developed and implemented trauma stress ulcer prophylaxis guidelines, and measured the impact of clinical pharmacists on implementing the guidelines and the effect of the guidelines on drug cost and frequency of major gastrointestinal bleeding. Two groups of 150 consecutive patients admitted with multiple trauma were evaluated before and after guideline implementation and stratified by Injury Severity Score (ISS) to minor (ISS < 9) or moderate to severe (ISS > or = 9) trauma groups. The number of patients prescribed stress ulcer prophylaxis, length and cost of this therapy, and number of patients experiencing major gastrointestinal bleeding (decrease in consecutive hemoglobin > or = 2 g/dl in conjunction with coffee-ground emesis, hematemesis, melena, or hematochezia) were measured. All pharmacist interventions pertaining to stress prophylaxis were collected. Fewer patients were prescribed stress ulcer prophylaxis after guideline implementation (105/150, 70% vs 39/150, 26%, p<0.0001), leading to a decrease in total drug cost of $4558. Use decreased more in patients with minor (40/54, 74% vs 9/59, 15%, p<0.0001) than moderate to severe (65/96, 68% vs 30/91, 33%, p<0.0001) trauma. Neither length of therapy nor agent of choice (> 95% cimetidine) differed between groups. Fifteen (38%) of 38 postguideline prophylaxis orders were determined by the pharmacist not to meet guideline criteria. Recommendations to discontinue therapy were accepted in 9 (60%) of 15 instances. The frequency of major gastrointestinal bleeding remained unchanged between groups (1/150 vs 0/150, p=1.0). Implementation of trauma stress ulcer prophylaxis guidelines limiting therapy to patients with risk factors for bleeding led to a 80% decrease in drug cost and did not affect the frequency of major gastrointestinal bleeding.