Adherence to stress-related mucosal damage prophylaxis guideline in patients admitted to the Intensive Care Unit

Pharmacokinetics of Esomeprazole in Critically Ill Patients

Background

Esomeprazole, a potent proton pump inhibitor (PPI), is widely used for the prevention of stress ulcers in intensive care unit (ICU) patients.

Objective

This study investigates the pharmacokinetics (PK) of esomeprazole in critically ill patients.

Methods

The study included eligible adult ICU patients who received endotracheal intubation assisted mechanical ventilation for more than 48 h and had at least an extra risk factor for stress ulcers. All enrolled patients received once-daily intravenous (IV) esomeprazole 40 mg. After the first dose of esomeprazole was administrated, serial blood samples were collected at 3, 5, 15, 30 min and 1, 2, 4, 6, 8, and 10 h. The total sample concentrations of esomeprazole were measured by UPLC-MS/MS. Esomeprazole PK parameters were analyzed using noncompartmental analysis.

Results

A total of 30 patients were evaluable. Mean age and body mass index (BMI) were 61.97 years and 23.14. PK sampling on the first dose resulted in the following median (IQR) parameters: AUC_0−∞ 8.06 (6.65–9.47) mg·h/L; MRT_0−∞ 4.70 (3.89–5.51) h; t_1/2 3.29 (2.7–3.87) h; V 24.89 (22.09–27.69) L; CL 6.13 (5.01–7.26) L/h; and C_max 2.56 (2.30–2.82) mg/L.

Conclusions

According to the label of esomeprazole, our study showed different esomeprazole PK parameters in ICU patients compared with healthy volunteers. Esomeprazole has unique pharmacokinetic parameters in critically ill patients.

INTENSIVE CARE UNIT PRESCRIPTIONS MUST FIT RISK FACTORS TO PREVENT STRESS ULCER BLEEDING

BACKGROUND

The physiological stress of critically ill patients can trigger several complications, including digestive bleeding due to stress ulcers (DBSU). The use of acid secretion suppressants to reduce their incidence has become widely used, but with the current understanding of the risks of these drugs, their use, as prophylaxis in critically ill patients, is limited to the patients with established risk factors.

AIM

To determine the appropriateness of the use of prophylaxis for stress ulcer bleeding in acutely ill patients admitted to intensive care units and to analyze the association of risk factors with adherence to the prophylaxis guideline.

METHODS

Retrospective, analytical study carried out in three general adult intensive care units. Electronic medical records were analyzed for epidemiological data, risk factors for DBSU, use of stress ulcer prophylaxis, occurrence of any digestive bleeding and confirmed DBSU. The daily analysis of risk factors and prophylaxis use were in accordance with criteria based on the Guidelines of the Portuguese Society of Intensive Care for stress ulcer prophylaxis.

RESULTS

One hundred and five patients were included. Of the patient days with the opportunity to prescribe prophylaxis, compliance was observed in 95.1%. Of the prescription days, 82.35% were considered to be of appropriate use. Overt digestive bleeding occurred in 3.81% of those included. The occurrence of confirmed DBSU was identified at 0.95%. Multivariate analysis by logistic regression did not identify risk factors independently associated with adherence to the guideline, but identified risk factors with a negative association, which were spinal cord injury (OR 0.02 p <0.01) and shock (OR 0.36 p=0.024).

CONCLUSION

The present study showed a high rate of adherence to stress ulcer prophylaxis, but with inappropriate use still significant. In the indication of prophylaxis, attention should be paid to patients with spinal cord injury and in shock.

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.

Appropriateness of Acid-suppressing Agents for Stress Ulcer Prophylaxis in Non-intensive Care Unit Setting in Saudi Arabia

Objective

To investigate the appropriateness of acid-suppressive therapy (AST) for stress ulcer prophylaxis (SUP) in noncritically ill hospitalized patients.

Materials and Methods

A prospective, observational study with 384 subjects was conducted between October and December 2017 in the emergency and internal medicine departments. The Herzig clinical risk scoring system and the guidelines of the American Society of Health-System Pharmacists guidelines were used to assess risk factors and determine risk scores for gastrointestinal (GI) bleeding.

Results

The mean age of subjects was 51.9 ± 19.4 years, and 220 (57.3%) of them were males. Among the absolute risk factors, coagulopathy was observed in 2 (0.5%) patients, mechanical ventilation in 15 (3.9%), and a history of GI bleeding in 1 (0.3%). Of 384 patients with SUP, 370 (96.4%) had a clinical risk score ≤ 9 and 14 (3.6%) had a risk score between 10 and 12 for nosocomial GI bleeding. A statistically significant relationship was found between the risk factor indication and demographics.

Conclusion

SUP is frequently administered to noncritically ill hospitalized patients lacking risk factors for GI bleeding. Proton pump inhibitors are the overwhelming first choice of AST among prescribers. Practitioners should follow international guidelines when prescribing ASTs outside the critical-care setting.

Variables Associated with Adherence to Stress Ulcer Prophylaxis in Patients Admitted to the General Hospital Wards: A Prospective Study

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.