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Liu Y, Feng DJ, Wang LF, Liu LH, Ren ZH, Hao JY, Li KB, Chen ML. The Impact of Cardiac Dysfunction Based on Killip Classification on Gastrointestinal Bleeding in Acute Myocardial Infarction. Front Med (Lausanne) 2022; 9:865663. [PMID: 35814749 PMCID: PMC9260836 DOI: 10.3389/fmed.2022.865663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Background Owing to limited data, the effect of cardiac dysfunction categorized according to the Killip classification on gastrointestinal bleeding (GIB) in patients with acute myocardial infarction (AMI) is unclear. The present study aimed to investigate the impact of cardiac dysfunction on GIB in patients with AMI and to determine if patients in the higher Killip classes are more prone to it. Methods This retrospective study was comprised of patients with AMI who were admitted to the cardiac intensive care unit in the Heart Center of the Beijing Chaoyang Hospital between December 2010 and June 2019. The in-hospital clinical data of the patients were collected. Both GIB and cardiac function, according to the Killip classification system, were confirmed using the discharge diagnosis of the International Classification of Diseases, Tenth Revision coding system. Univariate and multivariate conditional logistic regression models were constructed to test the association between GIB and the four Killip cardiac function classes. Results In total, 6,458 patients with AMI were analyzed, and GIB was diagnosed in 131 patients (2.03%). The multivariate logistic regression analysis showed that the risk of GIB was significantly correlated with the cardiac dysfunction [compared with the Killip class 1, Killip class 2’s odds ratio (OR) = 1.15, 95% confidence interval (CI): 0.73–1.08; Killip class 3’s OR = 2.63, 95% CI: 1.44–4.81; and Killip class 4’s OR = 4.33, 95% CI: 2.34–8.06]. Conclusion This study demonstrates that the degree of cardiac dysfunction in patients with acute myocardial infarction is closely linked with GIB. The higher Killip classes are associated with an increased risk of developing GIB.
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Affiliation(s)
- Yu Liu
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - De-Jing Feng
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Le-Feng Wang
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- *Correspondence: Le-Feng Wang,
| | - Li-Hong Liu
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Zheng-Hong Ren
- School of Public Health, Peking University Health Science Center, Beijing, China
| | - Jian-Yu Hao
- Department of Gastroenterology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Kui-Bao Li
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Mu-Lei Chen
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Lin TY, Chuang YC, Kao FC, Ping-Yeh C, Tsai TT, Fu TS, Lai PL. Early detection and intervention for acute perforated peptic ulcer after elective spine surgeries: a review of 13 cases from 24,026 patients. BMC Musculoskelet Disord 2021; 22:548. [PMID: 34134676 PMCID: PMC8210349 DOI: 10.1186/s12891-021-04443-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/07/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND To determine how perforated peptic ulcers be diagnosed earlier after patients undergoing an elective spine surgery. METHODS Patients who underwent elective spine surgeries at our hospital between January 2000 and April 2018 and experienced an acute perforated peptic ulcer were included. An age-and gender-matched control group was comprised of 26 patients without a postoperative acute perforated peptic ulcer who received spine surgery during the same period. Medical records and imaging studies were thoroughly reviewed. RESULTS Thirteen patients were enrolled in the study group, including eight females and five males. Three patients, two females and one male, died of uncontrolled peritonitis during the hospital stay. All patients in the study group experienced the sudden onset of abdominal pain, which was continuous and progressively worsening. Patients with elevated serum amylase, a peptic ulcer history and increased intraoperative blood loss had a tendency to develop a postoperative perforated peptic ulcer. CONCLUSION Spine surgeons should be highly alert to these risk factors of postoperative perforated peptic ulcers inpatients who has history of peptic ulcer, large amount ofintraoperative blood loss and abnormal high serum amylase level after elective spine surgery. Early diagnosis and emergent surgical intervention promote better outcomes.
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Affiliation(s)
- Tung-Yi Lin
- grid.454209.e0000 0004 0639 2551Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung branch, and Chang Gung University College of Medicine, Taoyuan, Taiwan, No. 222 Mai-King Road, Keelung, Taiwan
| | - Yu-Chun Chuang
- grid.454209.e0000 0004 0639 2551Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung branch, and Chang Gung University College of Medicine, Taoyuan, Taiwan, No. 222 Mai-King Road, Keelung, Taiwan
| | - Fu-Cheng Kao
- grid.413801.f0000 0001 0711 0593Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou branch, and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chiu Ping-Yeh
- grid.413801.f0000 0001 0711 0593Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou branch, and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tsung-Ting Tsai
- grid.413801.f0000 0001 0711 0593Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou branch, and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tsai-Sheng Fu
- grid.454209.e0000 0004 0639 2551Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung branch, and Chang Gung University College of Medicine, Taoyuan, Taiwan, No. 222 Mai-King Road, Keelung, Taiwan
| | - Po-Liang Lai
- grid.413801.f0000 0001 0711 0593Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou branch, and Chang Gung University College of Medicine, Taoyuan, Taiwan
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Choi YJ, Sim J, Jung YT, Shin S. Impact of a multidisciplinary quality improvement initiative to reduce inappropriate usage of stress ulcer prophylaxis in hospitalized patients. Br J Clin Pharmacol 2019; 86:903-912. [PMID: 31840265 DOI: 10.1111/bcp.14197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Yeo Jin Choi
- Clinical Trial Center, Hallym University Hospital, Anyang, Republic of Korea
| | - Joohyun Sim
- Department of Surgery, School of Medicine, Ajou University, Suwon, Republic of Korea
| | - Yun Tae Jung
- Department of Surgery, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Sooyoung Shin
- Department of Clinical Pharmacy, College of Pharmacy, Ajou University, Suwon, Republic of Korea.,Research Institute of Pharmaceutical Science and Technology (RIPST), Ajou University, Suwon, Republic of Korea
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Masood U, Sharma A, Bhatti Z, Carroll J, Bhardwaj A, Sivalingam D, Dhamoon AS. A Successful Pharmacist-Based Quality Initiative to Reduce Inappropriate Stress Ulcer Prophylaxis Use in an Academic Medical Intensive Care Unit. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2019; 55:46958018759116. [PMID: 29502481 PMCID: PMC5843103 DOI: 10.1177/0046958018759116] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Stress ulcer prophylaxis (SUP) is often inappropriately utilized, particularly in critically ill patients. The objective of this study is to find an effective way of reducing inappropriate SUP use in an academic medical intensive care unit (ICU). Medical ICU patients receiving SUP were identified over a 1-month period, and their charts were reviewed to determine whether American Society of Health-System Pharmacists guidelines were followed. Inappropriate usage was calculated as inappropriate patient-days and converted to incidence per 100 patient-days. Two interventions were implemented: (1) Pharmacists reviewed indications for SUP on each patient during daily team rounds and daily medication reconciliation and (2) residents rotating on ICU services were educated on a bimonthly basis. Postintervention data were obtained in a similar fashion. Prior to intervention, the incidence of inappropriate SUP usage was calculated to be 26.75 per 100 patient-days (n = 1099 total patient-days). Total cost attributable to the inappropriate use was $2433. Post intervention, we were able to decrease the inappropriate incidence of SUP usage to 7.14 per 100 patient-days (n = 1149 total patient-days). In addition, total cost of inappropriate use was reduced to $239.80. Our study highlights an effective multidisciplinary approach to reduce the inappropriate use of SUP in an academic medical ICU. We were able to reduce the incidence of inappropriate use of SUP by 73.31% (P < .001). Furthermore, we were able to decrease the costs by approximately $2200/month.
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Affiliation(s)
- Umair Masood
- 1 State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Anuj Sharma
- 1 State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Zabeer Bhatti
- 1 State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Jessica Carroll
- 1 State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Amit Bhardwaj
- 1 State University of New York Upstate Medical University, Syracuse, NY, USA
| | | | - Amit S Dhamoon
- 1 State University of New York Upstate Medical University, Syracuse, NY, USA
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Wei J, Jiang R, Li L, Kang D, Gao G, You C, Zhang J, Gao L, Huang Q, Luo D, Zhao G, Zhang H, Wang S, Wang R. Stress-related upper gastrointestinal bleeding in adult neurocritical care patients: a Chinese multicenter, retrospective study. Curr Med Res Opin 2019; 35:181-187. [PMID: 29499622 DOI: 10.1080/03007995.2018.1448261] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE China has limited data on stress-related gastrointestinal ulcers in patients admitted for neurosurgical care. This study evaluated the incidence of upper gastrointestinal bleeding (UGIB) and use of stress ulcer prophylaxis (SUP) in Chinese neurocritical care patients (Glasgow Coma Scale [GCS] score ≤10). METHODS This multicenter, retrospective study was performed from January 2015 to July 2015. Medical records of 1468 patients hospitalized during 2014 were reviewed. An estimated UGIB incidence rate of 4.4% was considered for precision of 1.3% for estimation of UGIB. The primary endpoint was evaluation of overall incidence of any overt UGIB in ≤14 days after cerebral lesion. Secondary endpoints included incidence of UGIB with or and without clinically significant complications, time to UGIB, associated risk factors and SUP used. RESULTS We analyzed 1416 patients (mean age: 53.7 ± 14.00 years; males: 62.4%) with cerebral lesions. Overall incidence rate of UGIB ≤14 days was 12.9% (95% CI: 11.2%-14.7%), 0.76% with and 12.1% without significant clinical complications. Average time and duration of bleeding were 2.9 ± 3.37 days and 4.2 ± 8.4 days, respectively. The most significant risk factors for UGIB were mechanical ventilation for >48 hours (p < .0001), UGIB history (p = .0026) and use of anticoagulants (p < .0001). Acid-suppression drugs were administered for SUP in 79.0% of the patients, whereas 40.5% received hemostatic drugs. CONCLUSIONS The rate of UGIB incidence was higher than the estimated rate in neurocritical care patients in China, suggesting the need for better management and treatment for stress-related mucosal disease in China. History of UGIB, mechanical ventilation and/or anticoagulants significantly affected UGIB. ClinicalTrials registry number: NCT02316990.
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Affiliation(s)
- Junji Wei
- a Department of Neurosurgery , Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College , Beijing , China
| | - Rongcai Jiang
- b Department of Neurosurgery , Tianjin Medical University General Hospital , Tianjin , China
| | - Lihong Li
- c Department of Neurosurgery , Tangdu Hospital of the Fourth Military Medical University , Xi'an , China
| | - Dezhi Kang
- d Department of Neurosurgery , the First Affiliated Hospital of Fujian Medical University , Fuzhou , China
| | - Guodong Gao
- c Department of Neurosurgery , Tangdu Hospital of the Fourth Military Medical University , Xi'an , China
| | - Chao You
- e Department of Neurosurgery, West China School of Medicine/West China Hospital , Sichuan University , Chengdu , China
| | - Jianmin Zhang
- f Department of Neurosurgery, the Second Affiliated Hospital of Zhejiang University School of Medicine , Hangzhou , China
| | - Liang Gao
- g Department of Neurosurgery , Shanghai Tenth People's Hospital/Tenth People's Hospital of Tongji University , Shanghai , China
| | - Qibing Huang
- h Department of Neurosurgery , Qilu Hospital of Shandong University , Jinan , China
| | - Duanwu Luo
- i Department of Neurosurgery , Xiangya Hospital Central South University , Changsha , China
| | - Gang Zhao
- j Department of Neurosurgery , the First Hospital of Jilin University , Changchun , China
| | - Hongyi Zhang
- k Department of Neurosurgery , Tangshan Gongren Hospital , Tangshan , China
| | - Shuo Wang
- l Department of Neurosurgery , Beijing Tian Tan Hospital, Capital Medical University , Beijing , China
| | - Renzhi Wang
- a Department of Neurosurgery , Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College , Beijing , China
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Yang QY, Ouyang J, Yang JD. Sepsis as an important risk factor for gastrointestinal bleeding in acute coronary syndrome patients: Two case reports. Medicine (Baltimore) 2018; 97:e12273. [PMID: 30200168 PMCID: PMC6133616 DOI: 10.1097/md.0000000000012273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Sepsis is a common stressor that may decrease microcirculation in the gastrointestinal tract in patients and increase the gastrointestinal bleeding risk of stress-related mucosal disease. However, the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines) bleeding risk score, recommended by authoritative guidelines for acute coronary syndrome (ACS), does not include sepsis as a bleeding risk factor. PATIENT CONCERNS The 2 cases were about ACS with hemorrhagic complications. The first patient was an 88-year-old man with hypertension, gallstones, hepatic cysts, and chest pain; the second one was a 79-year-old man with chest pain and hypertension. These 2 ACS patients had no bleeding on admission; however, both patients suffered apparent gastrointestinal bleeding immediately after the development of sepsis or severe sepsis. DIAGNOSES Both patients were diagnosed as ACS with sepsis. INTERVENTIONS The first ACS patient had no use of proton pump inhibitors (PPIs) for prophylaxis prior to the diagnosis of sepsis. The second one was administered PPIs at standard oral doses. OUTCOMES The first patient suffered from gastrointestinal bleeding immediately after the onset of sepsis. And oral PPIs failed to prevent upper gastrointestinal bleeding for the second patient, when severe sepsis developed. However, the second patient's gastrointestinal hemorrhage gradually stopped immediately after high doses of PPIs were administered intravenously, rather than orally. When sepsis developed again, the second patient also had no recurrent gastrointestinal bleeding under the protection of PPIs at standard oral doses. LESSONS Our report suggests that sepsis may be an important bleeding risk factor for ACS patients, and the reasonable use of PPIs to prevent gastrointestinal bleeding could be vital for ACS patients complicated with sepsis.
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Affiliation(s)
- Qi-Yu Yang
- Department of Thoracic Oncology, West China Hospital, Sichuan University, Chengdu, Sichuan
| | - Jing Ouyang
- Department of Pharmacy, Chongqing Public Health Medical Center
| | - Jia-Dan Yang
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Toews I, George AT, Peter JV, Kirubakaran R, Fontes LES, Ezekiel JPB, Meerpohl JJ. Interventions for preventing upper gastrointestinal bleeding in people admitted to intensive care units. Cochrane Database Syst Rev 2018; 6:CD008687. [PMID: 29862492 PMCID: PMC6513395 DOI: 10.1002/14651858.cd008687.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Upper gastrointestinal (GI) bleeding due to stress ulcers contributes to increased morbidity and mortality in people admitted to intensive care units (ICUs). Stress ulceration refers to GI mucosal injury related to the stress of being critically ill. ICU patients with major bleeding as a result of stress ulceration might have mortality rates approaching 48.5% to 65%. However, the incidence of stress-induced GI bleeding in ICUs has decreased, and not all critically ill patients need prophylaxis. Stress ulcer prophylaxis can result in adverse events such as ventilator-associated pneumonia; therefore, it is necessary to evaluate strategies that safely decrease the incidence of GI bleeding. OBJECTIVES To assess the effect and risk-benefit profile of interventions for preventing upper GI bleeding in people admitted to ICUs. SEARCH METHODS We searched the following databases up to 23 August 2017, using relevant search terms: MEDLINE; Embase; the Cochrane Central Register of Controlled Trials; Latin American Caribbean Health Sciences Literature; and the Cochrane Upper Gastrointestinal and Pancreatic Disease Group Specialised Register, as published in the Cochrane Library (2017, Issue 8). We searched the reference lists of all included studies and those from relevant systematic reviews and meta-analyses to identify additional studies. We also searched the World Health Organization International Clinical Trials Registry Platform search portal and contacted individual researchers working in this field, as well as organisations and pharmaceutical companies, to identify unpublished and ongoing studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs with participants of any age and gender admitted to ICUs for longer than 48 hours. We excluded studies in which participants were admitted to ICUs primarily for the management of GI bleeding and studies that compared different doses, routes, and regimens of one drug in the same class because we were not interested in intraclass effects of drugs. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as recommended by Cochrane. MAIN RESULTS We identified 2292 unique records.We included 129 records reporting on 121 studies, including 12 ongoing studies and two studies awaiting classification.We judged the overall risk of bias of two studies as low. Selection bias was the most relevant risk of bias domain across the included studies, with 78 studies not clearly reporting the method used for random sequence generation. Reporting bias was the domain with least risk of bias, with 12 studies not reporting all outcomes that researchers intended to investigate.Any intervention versus placebo or no prophylaxisIn comparison with placebo, any intervention seems to have a beneficial effect on the occurrence of upper GI bleeding (risk ratio (RR) 0.47, 95% confidence interval (CI) 0.39 to 0.57; moderate certainty of evidence). The use of any intervention reduced the risk of upper GI bleeding by 10% (95% CI -12.0% to -7%). The effect estimate of any intervention versus placebo or no prophylaxis with respect to the occurrence of nosocomial pneumonia, all-cause mortality in the ICU, duration of ICU stay, duration of intubation (all with low certainty of evidence), the number of participants requiring blood transfusions (moderate certainty of evidence), and the units of blood transfused was consistent with benefits and harms. None of the included studies explicitly reported on serious adverse events.Individual interventions versus placebo or no prophylaxisIn comparison with placebo or no prophylaxis, antacids, H2 receptor antagonists, and sucralfate were effective in preventing upper GI bleeding in ICU patients. Researchers found that with H2 receptor antagonists compared with placebo or no prophylaxis, 11% less developed upper GI bleeding (95% CI -0.16 to -0.06; RR 0.50, 95% CI 0.36 to 0.70; 24 studies; 2149 participants; moderate certainty of evidence). Of ICU patients taking antacids versus placebo or no prophylaxis, 9% less developed upper GI bleeding (95% CI -0.17 to -0.00; RR 0.49, 95% CI 0.25 to 0.99; eight studies; 774 participants; low certainty of evidence). Among ICU patients taking sucralfate versus placebo or no prophylaxis, 5% less had upper GI bleeding (95% CI -0.10 to -0.01; RR 0.53, 95% CI 0.32 to 0.88; seven studies; 598 participants; moderate certainty of evidence). The remaining interventions including proton pump inhibitors did not show a significant effect in preventing upper GI bleeding in ICU patients when compared with placebo or no prophylaxis.Regarding the occurrence of nosocomial pneumonia, the effects of H2 receptor antagonists (RR 1.12, 95% CI 0.85 to 1.48; eight studies; 945 participants; low certainty of evidence) and of sucralfate (RR 1.33, 95% CI 0.86 to 2.04; four studies; 450 participants; low certainty of evidence) were consistent with benefits and harms when compared with placebo or no prophylaxis. None of the studies comparing antacids versus placebo or no prophylaxis provided data regarding nosocomial pneumonia.H2 receptor antagonists versus proton pump inhibitorsH2 receptor antagonists and proton pump inhibitors are most commonly used in practice to prevent upper GI bleeding in ICU patients. Proton pump inhibitors significantly more often prevented upper GI bleeding in ICU patients compared with H2 receptor antagonists (RR 2.90, 95% CI 1.83 to 4.58; 18 studies; 1636 participants; low certainty of evidence). When taking H2 receptor antagonists, 4.8% more patients might experience upper GI bleeding (95% CI 2.1% to 9%). Nosocomial pneumonia occurred in similar proportions of participants taking H2 receptor antagonists and participants taking proton pump inhibitors (RR 1.02, 95% CI 0.77 to 1.35; 10 studies; 1256 participants; low certainty of evidence). AUTHORS' CONCLUSIONS This review shows that antacids, sucralfate, and H2 receptor antagonists might be more effective in preventing upper GI bleeding in ICU patients compared with placebo or no prophylaxis. The effect estimates of any treatment versus no prophylaxis on nosocomial pneumonia were consistent with benefits and harms. Evidence of low certainty suggests that proton pump inhibitors might be more effective than H2 receptor antagonists. Therefore, patient-relevant benefits and especially harms of H2 receptor antagonists compared with proton pump inhibitors need to be assessed by larger, high-quality RCTs to confirm the results of previously conducted, smaller, and older studies.
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Affiliation(s)
- Ingrid Toews
- Medical Center, Faculty of Medicine, University of FreiburgEvidence in Medicine / Cochrane GermanyBreisacher Straße 153FreiburgBaden‐WürttembergGermany79110
| | - Aneesh Thomas George
- Christian Medical CollegeCochrane South Asia, Prof. BV Moses Centre for Evidence‐Informed Healthcare and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
| | - John V Peter
- Christian Medical College & HospitalMedical Intensive Care UnitIda Scudder RoadVelloreTamil NaduIndia632004
| | - Richard Kirubakaran
- Christian Medical CollegeCochrane South Asia, Prof. BV Moses Centre for Evidence‐Informed Healthcare and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
| | - Luís Eduardo S Fontes
- Petrópolis Medical SchoolDepartment of Evidence‐Based Medicine, Intensive Care, GastroenterologyAv Barao do Rio Branco, 1003PetrópolisRJBrazil25680‐120
| | - Jabez Paul Barnabas Ezekiel
- Christian Medical CollegeCochrane South Asia, Prof. BV Moses Centre for Evidence‐Informed Healthcare and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
| | - Joerg J Meerpohl
- Medical Center, Faculty of Medicine, University of FreiburgEvidence in Medicine / Cochrane GermanyBreisacher Straße 153FreiburgBaden‐WürttembergGermany79110
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Cvetkovic A, Spasic M, Pavlovic M, Cvetkovic D, Stojanovic B, Ninkovic S, Jevdjic J, Canovic D, Milosevic B. The Use of Proton Pump Inhibitors in Intensive Care Units. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2018. [DOI: 10.1515/sjecr-2017-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
The bleeding from the upper gastrointestinal tract represent a significant medical but also socio-economic problem. A special group of patients et increased risk consists of critically ill patients in intensive care units. Particularly significant cause of bleeding in intensive care unit patients is bleeding resulting from the stress ulcers caused by damage of the mucosa of the stomach and duodenum.
The purpose of this review is to present current experience in prevention of upper gastrointestinal tract bleeding using proton pump inhibitors in intensive care units.
Combination of endoscopic hemostatic methods and proton pump inhibitors represents golden standard in most cases.
Despite some adverse effects treatment with proton pump blockers is essential when upper gastrointestinal tract bleeding appears in critically ill patients in intensive care units. Proton pump inhibitors are more effective in acid suppression, as well as in the prevention of recurrent bleeding after endoscopic hemostasis than histamine 2 receptor blockers. The efficacy of proton pump blockers is higher in the case of a continuous intravenous infusion than in the intermittent mode of administration of the drug. The need for highly elaborate strategy for the prophylaxis of bleeding from the upper parts of gastrointestinal tract in intensive care units is essential, because when it occurs in intensive care units, mortality is high, and therapeutic options become narrow.
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Affiliation(s)
| | - Marko Spasic
- Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Mladen Pavlovic
- Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Danijela Cvetkovic
- Faculty of Science, Department of Biology and Ecology , University of Kragujevac , Kragujevac , Serbia
| | - Bojan Stojanovic
- Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Srdjan Ninkovic
- Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Jasna Jevdjic
- Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Dragan Canovic
- Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Bojan Milosevic
- Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
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Sridharan K, Sivaramakrishnan G, Gnanaraj J. Pharmacological interventions for stress ulcer prophylaxis in critically ill patients: a mixed treatment comparison network meta-analysis and a recursive cumulative meta-analysis. Expert Opin Pharmacother 2017; 19:151-158. [DOI: 10.1080/14656566.2017.1419187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Gowri Sivaramakrishnan
- Prosthodontics, School of Oral Health, College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
| | - Jerome Gnanaraj
- Department of Medicine, Johns Hopkins Bayview Medical Center, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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10
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Farsaei S, Ghorbani S, Adibi P. Variables Associated with Adherence to Stress Ulcer Prophylaxis in Patients Admitted to the General Hospital Wards: A Prospective Study. Adv Pharm Bull 2017; 7:73-80. [PMID: 28507939 PMCID: PMC5426736 DOI: 10.15171/apb.2017.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 01/02/2017] [Accepted: 01/14/2017] [Indexed: 12/17/2022] Open
Abstract
Purpose: The dramatic increase in stress ulcer prophylaxis (SUP) prescribing patterns over the past several years has raised concerns regarding to their appropriate utilization. This prospective study attempted to evaluate the trend of adherence to stress ulcer prophylaxis from admission until discharge in non- Intensive care unit (ICU) setting. Additionally, we attempted to find those variables associated with appropriate SUP administration.
Methods: Data collection was performed prospectively to evaluate 195 randomly selected adult patients who received SUP or had indication for that in non-ICU wards of one of the largest referral center in Iran, during 6 months. Adherence was studied according to widely accepted American Society of Health system Pharmacists (ASHP) guideline. Univariate and multivariate logistic regression was also performed to detect associations related to misuse of SUP.
Results: We recognized total inappropriate use of SUP upon admission, during hospital stay and at discharge were somewhat identical at different time points (61%, 80% and 77.4% respectively). On the other hand, since small number of patients experienced SUP underutilization, unfortunately this was not possible to elucidate factors that may have effect on this flawed behavior. However, increasing age was identified to be significant variable in SUP overutilization.
Conclusion:
This prospective study highlighted inappropriate overutilization of SUP within non-critically ill patients and found factors which predicted this behavior. Adherence during hospital stay was also calculated for the first time in this study, which was related to SUP adherence upon hospital admission.
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Affiliation(s)
- Shadi Farsaei
- Department of Clinical Pharmacy and Pharmacy Practice, Isfahan Pharmaceutical Sciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sajad Ghorbani
- Department of Clinical Pharmacy and Pharmacy Practice, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Payman Adibi
- Department of Gastroenterology, Integrative Functional Gastroenterology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Boghossian TA, Rashid FJ, Thompson W, Welch V, Moayyedi P, Rojas‐Fernandez C, Pottie K, Farrell B. Deprescribing versus continuation of chronic proton pump inhibitor use in adults. Cochrane Database Syst Rev 2017; 3:CD011969. [PMID: 28301676 PMCID: PMC6464703 DOI: 10.1002/14651858.cd011969.pub2] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are a class of medications that reduce acid secretion and are used for treating many conditions such as gastroesophageal reflux disease (GERD), dyspepsia, reflux esophagitis, peptic ulcer disease, and hypersecretory conditions (e.g. Zollinger-Ellison syndrome), and as part of the eradication therapy for Helicobacter pylori bacteria. However, approximately 25% to 70% of people are prescribed a PPI inappropriately. Chronic PPI use without reassessment contributes to polypharmacy and puts people at risk of experiencing drug interactions and adverse events (e.g. Clostridium difficile infection, pneumonia, hypomagnesaemia, and fractures). OBJECTIVES To determine the effects (benefits and harms) associated with deprescribing long-term PPI therapy in adults, compared to chronic daily use (28 days or greater). SEARCH METHODS We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 10), MEDLINE, Embase, clinicaltrials.gov, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). The last date of search was November 2016. We handsearched the reference lists of relevant studies. We screened 2357 articles (2317 identified through search strategy, 40 through other resources). Of these articles, we assessed 89 for eligibility. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-randomized trials comparing at least one deprescribing modality (e.g. stopping PPI or reducing PPI) with a control consisting of no change in continuous daily PPI use in adult chronic users. Outcomes of interest were: change in gastrointestinal (GI) symptoms, drug burden/PPI use, cost/resource use, negative and positive drug withdrawal events, and participant satisfaction. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed and extracted data and completed the risk of bias assessment. A third review author independently confirmed risk of bias assessment. We used Review Manager 5 software for data analysis. We contacted study authors if there was missing information. MAIN RESULTS The review included six trials (n = 1758). Trial participants were aged 48 to 57 years, except for one trial that had a mean age of 73 years. All participants were from the outpatient setting and had either nonerosive reflux disease or milder grades of esophagitis (LA grade A or B). Five trials investigated on-demand deprescribing and one trial examined abrupt discontinuation. There was low quality evidence that on-demand use of PPI may increase risk of 'lack of symptom control' compared with continuous PPI use (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.31 to 2.21), thereby favoring continuous PPI use (five trials, n = 1653). There was a clinically significant reduction in 'drug burden', measured as PPI pill use per week with on-demand therapy (mean difference (MD) -3.79, 95% CI -4.73 to -2.84), favoring deprescribing based on moderate quality evidence (four trials, n = 1152). There was also low quality evidence that on-demand PPI use may be associated with reduced participant satisfaction compared with continuous PPI use. None of the included studies reported cost/resource use or positive drug withdrawal effects. AUTHORS' CONCLUSIONS In people with mild GERD, on-demand deprescribing may lead to an increase in GI symptoms (e.g. dyspepsia, regurgitation) and probably a reduction in pill burden. There was a decline in participant satisfaction, although heterogeneity was high. There were insufficient data to make a conclusion regarding long-term benefits and harms of PPI discontinuation, although two trials (one on-demand trial and one abrupt discontinuation trial) reported endoscopic findings in their intervention groups at study end.
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Affiliation(s)
- Taline A Boghossian
- The Ottawa HospitalDepartment of Pharmacy501 Smyth RoadOttawaONCanadaK1H 8L6
| | - Farah Joy Rashid
- The Ottawa HospitalDepartment of Pharmacy501 Smyth RoadOttawaONCanadaK1H 8L6
| | - Wade Thompson
- University of OttawaBruyère Research Institute43 rue Bruyere StRoom 730DOttawaONCanadaK1N 5C8
| | - Vivian Welch
- University of OttawaBruyère Research Institute43 rue Bruyere StRoom 730DOttawaONCanadaK1N 5C8
| | - Paul Moayyedi
- McMaster UniversityDepartment of Medicine, Division of Gastroenterology1200 Main Street WestRoom 4W8EHamiltonONCanadaL8N 3Z5
| | - Carlos Rojas‐Fernandez
- University of WaterlooSchool of Pharmacy10 Victoria St S.Room 7004KitchenerONCanadaN2G 1C5
| | - Kevin Pottie
- University of OttawaBruyère Research Institute43 rue Bruyere StRoom 730DOttawaONCanadaK1N 5C8
- University of OttawaFamily Medicine75 Bruyere StOttawaONCanadaK1N 5C8
| | - Barbara Farrell
- University of OttawaBruyère Research Institute43 rue Bruyere StRoom 730DOttawaONCanadaK1N 5C8
- University of WaterlooSchool of Pharmacy10 Victoria St S.Room 7004KitchenerONCanadaN2G 1C5
- University of OttawaFamily Medicine75 Bruyere StOttawaONCanadaK1N 5C8
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Lu T, Guan J. Combined application of nasogastric tubes and nasointestinal tubes in neurosurgical intensive care patients with stress ulceration: a novel solution to treatment and early enteral nutrition. SPRINGERPLUS 2016; 5:1769. [PMID: 27795911 PMCID: PMC5059544 DOI: 10.1186/s40064-016-3431-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 09/29/2016] [Indexed: 12/31/2022]
Abstract
Objective
Stress ulcers occur frequently in neurosurgical intensive care patients and can pose serious risks. We summarized the clinical experience of the combined application of nasointestinal tubes for early restoration of enteral nutrition and of nasogastric (NG) tubes for stress ulceration treatment in patients hospitalized in a neurosurgical intensive care unit. Methods From January 2011 to June 2011, a series of 67 patients with stress ulceration hospitalized in a neurosurgical intensive care unit were randomized to two groups. The control group (33 patients) received treatment with NG tube decompression and drainage according to international guidelines, and parenteral nutrition was changed to enteral feeding until there was no grossly visible blood in the NG tube. The nasointestinal tube group (34 patients) received treatment combining application of NG tubes and nasointestinal tubes. Drainage was performed with NG tubes as in the control group, with concurrent placement of nasointestinal tubes. Duration until resolution of stress ulceration and days until start of enteral nutrition were compared between the two groups. Results Duration until resolution of stress ulceration was 4.5 days in the control group and 4.3 days in the nasointestinal tube group. There was no difference between the two groups (P > 0.05). Duration until start of enteral nutrition was 4.5 days in the control group and 1 day in the nasointestinal tube group. There was an obvious difference between the two groups (P < 0.01). Conclusions The combined application of NG tubes and nasointestinal tubes in neurosurgical intensive care patients with stress ulceration is an effective means of treating stress ulceration and restoring early enteral nutrition.
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Affiliation(s)
- Tianshu Lu
- Department of Neurosurgery, The General Hospital of Shenyang Military Region, No. 83 Cultural Road, Shenyang, 110840 China
| | - Jingyu Guan
- Department of Neurosurgery, The General Hospital of Shenyang Military Region, No. 83 Cultural Road, Shenyang, 110840 China
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Kuo FC, Wu DC. Stress ulcer prophylaxis in the intensive care unit. ADVANCES IN DIGESTIVE MEDICINE 2014. [DOI: 10.1016/j.aidm.2014.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Pharmacological correction of stress-induced gastric ulceration by novel small-molecule agents with antioxidant profile. ScientificWorldJournal 2014; 2014:217039. [PMID: 24688371 PMCID: PMC3934458 DOI: 10.1155/2014/217039] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 12/25/2013] [Indexed: 01/06/2023] Open
Abstract
This study was designed to determine novel small-molecule agents influencing the pathogenesis of gastric lesions induced by stress. To achieve this goal, four novel organic compounds containing structural fragments with known antioxidant activity were synthesized, characterized by physicochemical methods, and evaluated in vivo at water immersion restraint conditions. The levels of lipid peroxidation products and activities of antioxidative system enzymes were measured in gastric mucosa and correlated with the observed gastroprotective activity of the active compounds. Prophylactic single-dose 1 mg/kg treatment with (2-hydroxyphenyl)thioacetyl derivatives of L-lysine and L-proline efficiently decreases up to 86% stress-induced stomach ulceration in rats. Discovered small-molecule antiulcer agents modulate activities of gastric mucosa tissue superoxide dismutase, catalase, and xanthine oxidase in concerted directions. Gastroprotective effect of (2-hydroxyphenyl)thioacetyl derivatives of L-lysine and L-proline at least partially depends on the correction of gastric mucosa oxidative balance.
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Sclerosing cholangitis in critically ill patients: an important and easily ignored problem based on a German experience. Front Med 2014; 8:118-26. [PMID: 24415157 DOI: 10.1007/s11684-014-0306-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 10/29/2013] [Indexed: 02/07/2023]
Abstract
Intensive care unit (ICU) is important in the rehabilitation of critically ill patients. In the past decades, many patients who received aggressive treatment in ICU developed sclerosing cholangitis in multiple centers. Sclerosing cholangitis in critically ill patients (SC-CIP) is a relatively new issue. To investigate the causes, clinical manifestation, treatment, and prognosis of SC-CIP, we searched for published cases in the databases of PubMed, Highwire, and Elsevier from 2001 to 2012. Data were extracted using a standard form and retrospectively analyzed. Twelve eligible studies covering 88 patients, with 64 men and 24 women, were enrolled in this analysis. The mean age was 49.8 years. All of the patients recovered from critical illnesses, such as trauma, infection, burn, and major surgeries. High pressure positive end-expiratory pressure (PEEP, peak level at 12.8 cm H₂O) was utilized for all patients, with the average duration of 36.3 d. In addition, vasopressor agents were administered in approximately 60%of SC-CIP. A rapid increase in cholestasis and irregular strictures in the intrahepatic bile ducts was observed in the following months. With an average follow-up period of 17.9 months, poor outcomes were observed in 54 patients, including 34 deaths. In conclusion, ischemic injury of the biliary tree, which may be affected by PEEP and/or vasopressor administration, affects cholangiopathic procedure. As a newly discovered type of secondary sclerosing cholangitis, SC-CIP is a severe progressive complication of patients in ICU and should be carefully monitored by clinicians.
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Messinger-Rapport BJ, Morley JE, Thomas DR, Gammack JK. Clinical Update on Nursing Home Medicine: 2011. J Am Med Dir Assoc 2011; 12:615-626.e6. [DOI: 10.1016/j.jamda.2011.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Accepted: 08/17/2011] [Indexed: 12/30/2022]
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Zeitoun A, Zeineddine M, Dimassi H. Stress ulcer prophylaxis guidelines: Are they being implemented in Lebanese health care centers? World J Gastrointest Pharmacol Ther 2011; 2:27-35. [PMID: 21860840 PMCID: PMC3158880 DOI: 10.4292/wjgpt.v2.i4.27] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2011] [Revised: 07/11/2011] [Accepted: 07/18/2011] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the current practice of stress ulcer prophylaxis (SUP) in Lebanese Health care centers. METHODS A multi-center prospective chart review study was conducted over 8 mo. A questionnaire was distributed to pharmacy students who collected data on demographics, SUP medications, dose, route, duration and associated risk factors. The appropriateness of SUP use was determined as per American Society of Health-System Pharmacists guidelines. Institutional review board approval was obtained from each hospital center. RESULTS A total of 1004 patients were included. 67% of the patients who received prophylaxis did not have an indication for SUP. The majority (71.6%) of the patients who were administered parenteral drugs can tolerate oral medications. Overall, the regimen of acid-suppressant drugs was suboptimal in 87.6% of the sample. This misuse was mainly observed in non-teaching hospitals. CONCLUSION This study highlighted the need, in Lebanese hospitals, to establish clinical practice guidelines for the use of SUP; mainly in non-critical care settings.
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Affiliation(s)
- Abeer Zeitoun
- Abeer Zeitoun, Maya Zeineddine, Hani Dimassi, Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, PO Box 36, Byblos, Lebanon
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Affiliation(s)
- Ladan Mohebbi
- Department of Pharmacy Services, Baylor University Medical Center, Dallas, Texas
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Critical Gastrointestinal Bleeding at an Inpatient Rehabilitation Center: Incidence, Risk Factors, and the Role of Gastrointestinal Prophylaxis. PM R 2010; 2:1104-12. [DOI: 10.1016/j.pmrj.2010.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 09/14/2010] [Accepted: 09/15/2010] [Indexed: 12/23/2022]
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George AT, Tharyan P, Peter JV, Kirubakaran R, Barnabas JP. Interventions for preventing upper gastrointestinal bleeding in people admitted to intensive care units. Hippokratia 2010. [DOI: 10.1002/14651858.cd008687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Aneesh Thomas George
- Christian Medical College; South Asian Cochrane Network & Centre, Prof. BV Moses & ICMR Advanced Centre for Research & Training in Evidence Informed Health Care; Carman Block II Floor CMC Campus, Bagayam Vellore Tamil Nadu India 632002
| | - Prathap Tharyan
- Christian Medical College; South Asian Cochrane Network & Centre, Prof. BV Moses & ICMR Advanced Centre for Research & Training in Evidence Informed Health Care; Carman Block II Floor CMC Campus, Bagayam Vellore Tamil Nadu India 632002
| | - John V Peter
- Christian Medical College & Hospital; Medical Intensive Care Unit; Ida Scudder Road Vellore Tamil Nadu India 632004
| | - Richard Kirubakaran
- Christian Medical College; South Asian Cochrane Network & Centre, Prof. BV Moses & ICMR Advanced Centre for Research & Training in Evidence Informed Health Care; Carman Block II Floor CMC Campus, Bagayam Vellore Tamil Nadu India 632002
| | - Jabez Paul Barnabas
- Christian Medical College; South Asian Cochrane Network & Centre, Prof. BV Moses & ICMR Advanced Centre for Research & Training in Evidence Informed Health Care; Carman Block II Floor CMC Campus, Bagayam Vellore Tamil Nadu India 632002
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Metz DC, Fulda GJ, Olsen KM, Monyak JT, Simonson SG, Sostek MB. Intravenous esomeprazole pharmacodynamics in critically ill patients. Curr Med Res Opin 2010; 26:1141-8. [PMID: 20230209 DOI: 10.1185/03007991003694308] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE A widely held belief contends that food-induced proton pump activation is important for optimal proton pump inhibitor-induced inhibition of gastric acid secretion. This study was undertaken to assess intragastric acid control with intravenous (IV) esomeprazole in critically ill patients. RESEARCH DESIGN AND METHODS This open-label, single-arm, exploratory trial was conducted at five university or regional hospital intensive care units in the US. Adult patients admitted to an intensive care unit who required mechanical ventilation and had at least one additional risk factor for stress-induced ulcer received twice-daily IV esomeprazole 40 mg for 48 hours and could continue for another 24 hours if no prepyloric enteral feedings were planned. CLINICAL TRIAL REGISTRATION D9612L00107; ClinicalTrials.gov Identifier NCT00428701. MAIN OUTCOME MEASURES The primary efficacy variable was the linear-interpolated percentage of time intragastric pH was > or =4 during 24-48 hours. Secondary efficacy variables included the interpolated percentage of time intragastric pH was > or =4 during 0-24, 0-48, and 48-72 hours, the percentage of gastric aspirates collected with pH > or =4 during 0-24, 24-48, 0-48, and 48-72 hours, and time to stable pH > or =4. Safety was assessed based on adverse events (AEs), physical examinations, vital signs, laboratory tests, and electrocardiograms. RESULTS Forty-five patients were enrolled (one was excluded because of previous partial gastrectomy). Interpolated mean percentage time pH > or =4 was 88.8%, 80.7%, and 83.5% for 24-48, 0-24, and 0-48 hours, respectively. For 0-72 hours, > or =78% of gastric aspirates had pH > or =4. Median time to stable pH was 1 hour (95% confidence interval: 0.67, 2.00). Treatment was well tolerated, with no evidence of gastrointestinal bleeding. A total of 75 AEs occurred in 34 patients, none considered treatment related. CONCLUSIONS In this noncontrolled exploratory study, twice-daily IV esomeprazole 40 mg rapidly decreased intragastric acidity and effectively maintained pH >/=4 during 0-72 hours in fasting, critically ill, mechanically ventilated patients at high risk for stress ulcers.
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Affiliation(s)
- David C Metz
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Stress ulcer, gastritis, and gastrointestinal bleeding prophylaxis in critically ill pediatric patients: a systematic review. Pediatr Crit Care Med 2010; 11:124-32. [PMID: 19770788 DOI: 10.1097/pcc.0b013e3181b80e70] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify and evaluate the quality of evidence supporting prophylactic use of treatments for stress ulcers and upper gastrointestinal bleeding. Stress ulcers, erosions of the stomach and duodenum, and upper gastrointestinal bleeding are well-known complications of critical illness in children admitted to the pediatric intensive care unit. DATA SOURCES Studies were identified from the Cochrane Central Register of Controlled Trials, PUBMED; LILACS; Scirus. We also scanned bibliographies of relevant studies. STUDY SELECTION This systematic review of randomized controlled trials assessed the effects of drugs for stress-related ulcers, gastritis, and upper gastrointestinal bleeding in critically ill children admitted to the pediatric intensive care unit. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted the relevant data. Most randomized controlled trials were judged as having unclear risk of bias. When pooling two randomized controlled trials, treatment was significantly more effective in preventing upper gastrointestinal bleeding (macroscopic or important bleeding) compared with no treatment (two studies = 300 participants; relative risk, 0.41; 95% confidence interval, 0.19-0.91; I = 12%). Meta-analysis of two studies found no significant difference in death rates among groups (two randomized controlled trials = 132 participants; relative risk, 1.39; 95% confidence interval, 0.70-2.79; I = 4%). The rate of pneumonia was not significantly different when comparing treatment and no treatment in one study. When comparing ranitidine with no treatment, significant differences were found in the proportion of mechanically ventilated children with normal gastric mucosal endoscopic findings by histologic specimens (one randomized controlled trial = 48 participants; relative risk, 3.53; 95% confidence interval, 1.34-9.29). No significant differences were found when comparing different drugs (omeprazole, ranitidine, sucralfate, famotidine, amalgate), doses, or regimens for main outcomes (deaths, endoscopic findings of erosion or ulcers, upper gastrointestinal bleeding, or pneumonia). CONCLUSIONS Although pooled data of two studies suggested that critically ill pediatric patients may benefit from receiving prophylactic treatment to prevent upper gastrointestinal bleeding, we found that high-quality evidence to guide clinical practice is still limited.
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Abstract
PURPOSE OF REVIEW To discuss the risk factors and underlying illnesses that play a role in the pathophysiology of stress ulcer, and to evaluate the evidence pertaining to stress ulcer-related bleeding prophylaxis in critically ill patients. RECENT FINDINGS The use of stress ulcer prophylaxis is common in critical care medicine and is a major challenge to physicians in the ICU. The mechanism of stress ulcer is believed to be multifactorial, yet remains incompletely understood. The most widely used drugs for stress ulcer prophylaxis are intravenous histamine2-receptor antagonists. They raise gastric pH, but are associated with the development of tolerance, possible drug interactions, and neurologic manifestations. Sucralfate, which can be administered by the nasogastric route, can protect the gastric mucosa without raising pH, but may decrease absorption of concomitantly administered oral medications. Proton pump inhibitors are the most potent acid-inhibiting pharmacologic agents available. Proton pump inhibitors are at least as effective as histamine2-receptor antagonists, as a limited number of clinical trials have demonstrated. However, these trials were small, lacked an active comparator, varied in the number of risk factors, and used a different definition of clinically important bleeding than previously established. SUMMARY Routine prophylaxis against stress ulcers in the ICU is not well justified by current evidence. Patients at risk of stress ulcer-related bleeding are most likely to benefit from prophylaxis. Thus, healthcare professionals should continue to evaluate risk and assess the need for stress ulcer-related prophylaxis.
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Abstract
Increased knowledge of risk factors and improved ICU care has decreased the incidence of stress-related bleeding. Not all critically ill patients need prophylaxis for SRMD and withholding such prophylaxis in suitable low-risk candidates is a reasonable and cost-effective approach. Mechanical ventilation for more than 48 hours and coagulopathy are the main risk factors for stress-induced upper GI bleeding. Although intravenous H2RAs can prevent clinically important bleeding, their benefits seem to be limited by the rapid development of tolerance. The availability of intravenous formulations of PPIs makes it possible to critically compare their prophylactic efficacy and safety to different classes of acid-suppressive agents, such as H2RAs, in critically ill patients. The appropriate dose of PPI and the role of newer PPI formulations need to be further defined along with proposed guidelines for the use of intravenous and oral/enteral formulations of PPIs in patients at risk for stress-related mucosal damage.
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Affiliation(s)
- Tauseef Ali
- Section of Digestive Diseases and Nutrition, Department of Internal Medicine, University of Oklahoma Health Sciences Center, 1360 WP, 920 SL Young Boulevard, Oklahoma City, OK 73104, USA
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Abstract
Physiologic stress associated with illness and hospitalization is known to result in gastrointestinal ulceration, especially among the critically ill. The complication of this stress-related mucosal disease could be prevented with appropriate application of pharmacologic prophylaxis. Vigilance by the nursing staff is required to properly detect and manage the condition.
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Sesler JM. Stress-related mucosal disease in the intensive care unit: an update on prophylaxis. AACN Adv Crit Care 2007; 18:119-26; quiz 127-8. [PMID: 17473539 DOI: 10.1097/01.aacn.0000269254.39967.8e] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Gastric ulcers have been known to develop in critically ill patients secondary to physiological stress since the 19th century. It is only relatively recently that stress ulcer prophylaxis has become an established routine practice in the intensive care unit. Numerous terms have been used to describe stress ulcers, but stress-related mucosal disease (SRMD) is commonly used. Significant morbidity and mortality in critically ill patients is caused by SRMD and related bleedings, but the incidence depends on the definition of bleeding. Pathophysiology of SRMD is multifactorial and involves a complex set of interactions that causes a breakdown of mucosal proactive defenses, leading to ulceration. Critically ill patients are at an increased risk for developing SRMD and subsequent bleeding secondary to several risk factors. To minimize stress-related mucosal bleeding, several regimens have been used. This article presents an update on the incidence, pathophysiology, risk factors, and prophylaxis of SRMD.
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Affiliation(s)
- Jefferson M Sesler
- Department of Pharmacy Services, University of Virginia Health Sciences, PO Box 800674, Charlottesville, VA 22908, USA.
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