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Toews I, Hussain S, Nyirenda JLZ, Willis MA, Kantorová L, Slezáková S, Boltena MT, Victor PJ, Fontes LES, Klugar M, Sadeghirad B, Meerpohl JJ. Pharmacological interventions for preventing upper gastrointestinal bleeding in people admitted to intensive care units: a network meta-analysis. BMJ Evid Based Med 2024:bmjebm-2024-112886. [PMID: 38997152 DOI: 10.1136/bmjebm-2024-112886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2024] [Indexed: 07/14/2024]
Abstract
OBJECTIVES To assess the efficacy and safety of pharmacological interventions for preventing upper gastrointestinal (GI) bleeding in people admitted to intensive care units (ICUs). DESIGN AND SETTING Systematic review and frequentist network meta-analysis using standard methodological procedures as recommended by Cochrane for screening of records, data extraction and analysis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence. PARTICIPANTS Randomised controlled trials involving patients admitted to ICUs for longer than 24 hours were included. SEARCH METHODS The Cochrane Gut Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Latin American and Caribbean Health Science Information database (LILACS) databases were searched from August 2017 to March 2022. The search in MEDLINE was updated in April 2023. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). MAIN OUTCOME MEASURES The primary outcome was the prevention of clinically important upper GI bleeding. RESULTS We included 123 studies with 46 996 participants. Cimetidine (relative risk (RR) 0.56, 95% CI 0.40 to 0.77, moderate certainty), ranitidine (RR 0.54, 95% CI 0.38 to 0.76, moderate certainty), antacids (RR 0.48, 95% CI 0.33 to 0.68, moderate certainty), sucralfate (RR 0.54, 95% CI 0.39 to 0.75, moderate certainty) and a combination of ranitidine and antacids (RR 0.13, 95% CI 0.03 to 0.62, moderate certainty) are likely effective in preventing upper GI bleeding.The effect of any intervention on the prevention of nosocomial pneumonia, all-cause mortality in the ICU or the hospital, duration of the stay in the ICU, duration of intubation and (serious) adverse events remains unclear. CONCLUSIONS Several interventions seem effective in preventing clinically important upper GI bleeding while there is limited evidence for other outcomes. Patient-relevant benefits and harms need to be assessed under consideration of the patients' underlying conditions.
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Affiliation(s)
- Ingrid Toews
- Institute for Evidence in Medicine, Medical Center - Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Salman Hussain
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - John L Z Nyirenda
- Institute for Evidence in Medicine, Medical Center - Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Maria A Willis
- Department of General, Visceral, Thorax and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Lucia Kantorová
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Simona Slezáková
- Cochrane Czech Republic, Czech Republic: a JBI Centre of Excellence, Czech GRADE Network, Institute of Health Information and Statistics of the Czech Republic, Prague, Czech Republic
| | - Minyahil Tadesse Boltena
- Ethiopian Evidence Based Health Care Center, Institute of Health, A Joanna Briggs Institute's Center of Excellence, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Peter John Victor
- Medical Intensive Care Unit, Christian Medical College & Hospital, Vellore, India
| | | | - Miloslav Klugar
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Center of Evidence-Based Education and Arts Therapies: A JBI Affiliated Group, Palacky University Olomouc Faculty of Education, Olomouc, Olomoucký, Czech Republic
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine, Medical Center - Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
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Prevalence of Gastric Ulceration in Horses with Enterolithiasis Compared with Horses with Simple Large Intestinal Obstruction. Vet Sci 2022; 9:vetsci9110587. [PMID: 36356064 PMCID: PMC9698009 DOI: 10.3390/vetsci9110587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 10/19/2022] [Accepted: 10/24/2022] [Indexed: 11/16/2022] Open
Abstract
Enterolithiasis is a well-documented cause of colic in horses, especially in some geographic areas such as California and Florida. This retrospective case-control study aims at comparing the prevalence of gastric ulcers in horses affected by enterolithiasis to that in horses affected by other types of large intestinal obstruction. Two hundred and ninety-six horses were included in the study sample. Horses that had surgery for the removal of one or more enteroliths were included in the study as cases. Patients that had surgery for large intestinal simple obstructions other than enterolithiasis (large colon displacement, non-strangulating large colon torsion, and large and small colon impactions) were selected to match case horses for age, sex, and breed and included as controls. A total of 101/148 horses with enteroliths (68%) had gastric ulcers diagnosed during hospitalization, compared with 46/148 of matched controls (31%). There was a significant association between enterolithiasis and gastric ulceration (odds ratio 4.76, p < 0.0001), and a greater prevalence in Thoroughbreds as compared with other breeds (odds ratio 22.6, p < 0.0001). We concluded that enterolithiasis is significantly associated with gastric ulceration (p < 0.0001). The association is stronger in Thoroughbreds.
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Rachfalska N, Putowski Z, Krzych ŁJ. Distant Organ Damage in Acute Brain Injury. Brain Sci 2020; 10:E1019. [PMID: 33371363 PMCID: PMC7767338 DOI: 10.3390/brainsci10121019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/15/2020] [Accepted: 12/18/2020] [Indexed: 02/07/2023] Open
Abstract
Acute brain injuries pose a great threat to global health, having significant impact on mortality and disability. Patients with acute brain injury may develop distant organ failure, even if no systemic diseases or infection is present. The severity of non-neurologic organs' dysfunction depends on the extremity of the insult to the brain. In this comprehensive review we sought to describe the organ-related consequences of acute brain injuries. The clinician should always be aware of the interplay between central nervous system and non-neurological organs, that is constantly present. Cerebral injury is not only a brain disease, but also affects the body as whole, and thus requires holistic therapeutical approach.
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Affiliation(s)
| | | | - Łukasz J. Krzych
- Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-055 Katowice, Poland; (N.R.); (Z.P.)
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4
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Wang Y, Ge L, Ye Z, Siemieniuk RA, Reintam Blaser A, Wang X, Perner A, Møller MH, Alhazzani W, Cook D, Guyatt GH. Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: an updated systematic review and network meta-analysis of randomized trials. Intensive Care Med 2020; 46:1987-2000. [PMID: 32833040 DOI: 10.1007/s00134-020-06209-w] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 08/01/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Motivated by a new randomized trial (the PEPTIC trial) that raised the issue of an increase in mortality with proton pump inhibitors (PPIs) relative to histamine-2 receptor antagonists (H2RAs), we updated our prior systematic review and network meta-analysis (NMA) addressing the impact of pharmacological gastrointestinal bleeding prophylaxis in critically ill patients. METHODS We searched for randomized controlled trials that examined the efficacy and safety of gastrointestinal bleeding prophylaxis with PPIs, H2RAs, or sucralfate versus one another or placebo or no prophylaxis in adult critically ill patients. We performed Bayesian random-effects NMA and conducted analyses using all PEPTIC data as well as a restricted analysis using only PEPTIC data from high compliance centers. We used the GRADE approach to quantify absolute effects and assess the certainty of evidence. RESULTS Seventy-four trials enrolling 39 569 patients proved eligible. Both PPIs (risk ratio (RR) 1.03, 95% credible interval 0.93 to 1.14, moderate certainty) and H2RAs (RR 0.98, 0.89 to 1.08, moderate certainty) probably have little or no impact on mortality compared with no prophylaxis. There may be no important difference between PPIs and H2RAs on mortality (RR 1.05, 0.97 to 1.14, low certainty), the 95% credible interval of the complete analysis has not excluded an important increase in mortality with PPIs. Both PPIs (RR 0.46, 0.29 to 0.66) and H2RAs (RR 0.67, 0.48 to 0.94) probably reduce clinically important gastrointestinal bleeding; the magnitude of reduction is probably greater in PPIs than H2RAs (RR 0.69, 0.45 to 0.93), and the difference may be important in higher, but not lower bleeding risk patients. PPIs (RR 1.08, 0.88 to 1.45, low certainty) and H2RAs (RR 1.07, 0.85 to 1.37, low certainty) may have no important impact on pneumonia compared with no prophylaxis. CONCLUSION This updated NMA confirmed that PPIs and H2RAs are most likely to have a similar effect on mortality compared to each other and compared to no prophylaxis; however, the possibility that PPIs may slightly increase mortality cannot be excluded (low certainty evidence). PPIs and H2RAs probably achieve important reductions in clinically important gastrointestinal bleeding; for higher bleeding risk patients, the greater benefit of PPIs over H2RAs may be important. PPIs or H2RAs may not result in important increases in pneumonia but the certainty of evidence is low.
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Affiliation(s)
- Ying Wang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Long Ge
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Zhikang Ye
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Reed A Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Annika Reintam Blaser
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.,Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
| | - Xin Wang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Morten H Møller
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Deborah Cook
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada. .,Department of Medicine, McMaster University, Hamilton, Canada.
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Marker S, Barbateskovic M, Perner A, Wetterslev J, Jakobsen JC, Krag M, Granholm A, Anthon CT, Møller MH. Prophylactic use of acid suppressants in adult acutely ill hospitalised patients: A systematic review with meta-analysis and trial sequential analysis. Acta Anaesthesiol Scand 2020; 64:714-728. [PMID: 32060905 DOI: 10.1111/aas.13568] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/31/2020] [Accepted: 02/12/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Acutely ill patients are at risk of stress-related gastrointestinal (GI) bleeding and prophylactic acid suppressants are frequently used. In this systematic review, we assessed the effects of stress ulcer prophylaxis (SUP) with proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) versus placebo or no prophylaxis in acutely ill hospitalised patients. METHODS We conducted the review according to the PRISMA statement, the Cochrane Handbook and GRADE, using conventional meta-analysis and trial sequential analysis (TSA). The primary outcomes were all-cause mortality, clinically important GI bleeding and serious adverse events (SAEs). The primary analyses included overall low risk of bias trials. RESULTS We included 65 comparisons from 62 trials (n = 9713); 43 comparisons were from intensive care units. Only three trials (n = 3596) had overall low risk of bias. We did not find an effect on all-cause mortality (RR 1.03, 95% CI 0.94 to 1.14; TSA-adjusted CI 0.90 to 1.18; high certainty). The rate of clinically important GI bleeding was lower with SUP (RR 0.62, 95% CI 0.43 to 0.89; TSA-adjusted CI 0.14 to 2.81; moderate certainty). We did not find a difference in pneumonia rates (moderate certainty). Effects on SAEs, Clostridium difficile enteritis, myocardial ischaemia and health-related quality of life (HRQoL) were inconclusive due to sparse data. Analyses of all trials regardless of risk of bias were consistent with the primary analyses. CONCLUSIONS We did not observe a difference in all-cause mortality or pneumonia with SUP. The incidence of clinically important GI bleeding was reduced with SUP, whereas any effects on SAEs, myocardial ischaemia, Clostridium difficile enteritis and HRQoL were inconclusive. STUDY REGISTRATION PROSPERO registration number CRD42017055676; published study protocol: Marker, et al 2017 in Systematic Reviews.
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Affiliation(s)
- Søren Marker
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Marija Barbateskovic
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
- Copenhagen Trial Unit Centre for Clinical Intervention Research Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Jørn Wetterslev
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
- Copenhagen Trial Unit Centre for Clinical Intervention Research Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Janus C. Jakobsen
- Copenhagen Trial Unit Centre for Clinical Intervention Research Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Department of Cardiology Holbaek Hospital Holbaek Denmark
- Department of Regional Health Research The Faculty of Heath Sciences University of Southern Denmark Odense Denmark
| | - Mette Krag
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Anders Granholm
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Carl T. Anthon
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Morten H. Møller
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
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Liu Y, Li D, Wen A. Pharmacologic Prophylaxis of Stress Ulcer in Non-ICU Patients: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials. Clin Ther 2020; 42:488-498.e8. [PMID: 32046894 DOI: 10.1016/j.clinthera.2020.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 01/07/2020] [Accepted: 01/14/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Acid-suppressive medications are widely used in non-intensive care unit (non-ICU) patients for stress ulcer (SU) prophylaxis. However, SU prophylaxis in this population is still controversial. The purpose of this study was to systematically evaluate the efficacy and tolerability of these agents for SU prophylaxis in non-ICU patients. METHODS Electronic databases including Cochrane, ClinicalTrials.gov, Ovid-Medline, Embase, Chinese CNKI, and Wanfang Data were systematically searched on July 10, 2019, for randomized controlled trials (RCTs) that evaluated acid-suppressive medications in non-ICU patients. Network meta-analysis and pairwise meta-analysis were performed to calculate odds ratios (ORs) and 95% CIs. A random-effects model was used for generating pooled estimates. The primary outcome was occurrence of SU bleeding, and the adverse drug events (ADEs) were described as the secondary outcome. FINDINGS A total of 17 RCTs involving 1985 patients were eligible. Meta-analysis results indicated that the occurrence of SU bleeding was significantly decreased with all acid-suppressive medications compared with placebos (gastric mucosa protectants, OR = 0.29 [95% CI, 0.14-0.61]; H2-receptor antagonists, OR = 0.3 [95% CI, 0.18-0.50]; proton pump inhibitors [PPIs]: OR = 0.08 [95% CI, 0.04-0.16]). The occurrence of SU bleeding was significantly decreased with PPIs compared with gastric mucosa protectants (OR = 0.29; 95% CI, 0.12-0.72) and H2-receptor antagonists (OR = 0.28; 95% CI, 0.16-0.48). There was no significant difference between any 2 classes of PPIs on SU bleeding or any 2 acid-suppressive medications on ADEs. IMPLICATIONS PPIs could significantly decrease SU bleeding risk without increasing ADEs than other acid-suppressive medications for SU prophylaxis in non-ICU patients. However, RCTs of high quality were required to confirm the findings of this investigation.
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Affiliation(s)
- Yi Liu
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Dandan Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Aiping Wen
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
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Wang Y, Ye Z, Ge L, Siemieniuk RAC, Wang X, Wang Y, Hou L, Ma Z, Agoritsas T, Vandvik PO, Perner A, Møller MH, Guyatt GH, Liu L. Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: systematic review and network meta-analysis. BMJ 2020; 368:l6744. [PMID: 31907166 PMCID: PMC7190057 DOI: 10.1136/bmj.l6744] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine, in critically ill patients, the relative impact of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), sucralfate, or no gastrointestinal bleeding prophylaxis (or stress ulcer prophylaxis) on outcomes important to patients. DESIGN Systematic review and network meta-analysis. DATA SOURCES Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials, trial registers, and grey literature up to March 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES AND METHODS We included randomised controlled trials that compared gastrointestinal bleeding prophylaxis with PPIs, H2RAs, or sucralfate versus one another or placebo or no prophylaxis in adult critically ill patients. Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias. A parallel guideline committee (BMJ Rapid Recommendation) provided critical oversight of the systematic review, including identifying outcomes important to patients. We performed random-effects pairwise and network meta-analyses and used GRADE to assess certainty of evidence for each outcome. When results differed between low risk and high risk of bias studies, we used the former as best estimates. RESULTS Seventy two trials including 12 660 patients proved eligible. For patients at highest risk (>8%) or high risk (4-8%) of bleeding, both PPIs and H2RAs probably reduce clinically important gastrointestinal bleeding compared with placebo or no prophylaxis (odds ratio for PPIs 0.61 (95% confidence interval 0.42 to 0.89), 3.3% fewer for highest risk and 2.3% fewer for high risk patients, moderate certainty; odds ratio for H2RAs 0.46 (0.27 to 0.79), 4.6% fewer for highest risk and 3.1% fewer for high risk patients, moderate certainty). Both may increase the risk of pneumonia compared with no prophylaxis (odds ratio for PPIs 1.39 (0.98 to 2.10), 5.0% more, low certainty; odds ratio for H2RAs 1.26 (0.89 to 1.85), 3.4% more, low certainty). It is likely that neither affect mortality (PPIs 1.06 (0.90 to 1.28), 1.3% more, moderate certainty; H2RAs 0.96 (0.79 to 1.19), 0.9% fewer, moderate certainty). Otherwise, results provided no support for any affect on mortality, Clostridium difficile infection, length of intensive care stay, length of hospital stay, or duration of mechanical ventilation (varying certainty of evidence). CONCLUSIONS For higher risk critically ill patients, PPIs and H2RAs likely result in important reductions in gastrointestinal bleeding compared with no prophylaxis; for patients at low risk, the reduction in bleeding may be unimportant. Both PPIs and H2RAs may result in important increases in pneumonia. Variable quality evidence suggested no important effects of interventions on mortality or other in-hospital morbidity outcomes. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019126656.
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Affiliation(s)
- Ying Wang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Zhikang Ye
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Long Ge
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Reed A C Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Xin Wang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yingkai Wang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Liangying Hou
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Zhuo Ma
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Division of General Internal Medicine and Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | | | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Morten H Møller
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Lihong Liu
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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8
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Zhou X, Fang H, Xu J, Chen P, Hu X, Chen B, Wang H, Hu C, Xu Z. Stress ulcer prophylaxis with proton pump inhibitors or histamine 2 receptor antagonists in critically ill adults - a meta-analysis of randomized controlled trials with trial sequential analysis. BMC Gastroenterol 2019; 19:193. [PMID: 31752703 PMCID: PMC6873751 DOI: 10.1186/s12876-019-1105-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 10/30/2019] [Indexed: 02/08/2023] Open
Abstract
Background Proton pump inhibitors (PPI) and histamine 2 receptor antagonists (H2RA) have been widely used as stress ulcer prophylaxis (SUP) in critically ill patients, however, its efficacy and safety remain unclear. This study aimed to assess the effect of SUP on clinical outcomes in critically ill adults. Methods Literature search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane database of clinical trials for randomized controlled trials (RCTs) that investigated SUP, with PPI or H2RA, versus placebo or no prophylaxis in critically ill patients from database inception through 1 June 2019. Study selection, data extraction and quality assessment were performed in duplicate. The primary outcomes were clinically important gastrointestinal (GI) bleeding and overt GI bleeding. Conventional meta-analysis with random-effects model and trial sequential analysis (TSA) were performed. Results Twenty-nine RCTs were identified, of which four RCTs were judged as low risk of bias. Overall, SUP could reduce the incident of clinically important GI bleeding [relative risk (RR) = 0.58; 95% confidence intervals (CI): 0.42–0.81] and overt GI bleeding (RR = 0.48; 95% CI: 0.36–0.63), these results were confirmed by the sub-analysis of trials with low risk of bias, TSA indicated a firm evidence on its beneficial effects on the overt GI bleeding (TSA-adjusted CI: 0.31–0.75), but lack of sufficient evidence on the clinically important GI bleeding (TSA-adjusted CI: 0.23–1.51). Among patients who received enteral nutrition (EN), SUP was associated with a decreased risk of clinically important GI bleeding (RR = 0.61; 95% CI: 0.44–0.85; TSA-adjusted CI: 0.16–2.38) and overt GI bleeding (RR = 0.64; 95% CI: 0.42–0.96; TSA-adjusted CI: 0.12–3.35), but these benefits disappeared after adjustment with TSA. Among patients who did not receive EN, SUP had only benefits in reducing the risk of overt GI bleeding (RR = 0.37; 95% CI: 0.25–0.55; TSA-adjusted CI: 0.22–0.63), but not the clinically important GI bleeding (RR = 0.27; 95% CI: 0.04–2.09). Conclusions SUP has benefits on the overt GI bleeding in critically ill patients who did not receive EN, however, its benefits on clinically important GI bleeding still needs more evidence to confirm.
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Affiliation(s)
- Xiaoyang Zhou
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Hanyuan Fang
- Department of Emergency, Ningbo Yinzhou No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Jianfei Xu
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Peifu Chen
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Xujun Hu
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Bixin Chen
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Hua Wang
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Caibao Hu
- Department of Intensive Care Medicine, Zhejiang Hospital, Hangzhou, 310000, Zhejiang, China.
| | - Zhaojun Xu
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China.
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Hill TL. Gastrointestinal Tract Dysfunction With Critical Illness: Clinical Assessment and Management. Top Companion Anim Med 2019; 35:47-52. [PMID: 31122688 DOI: 10.1053/j.tcam.2019.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 04/08/2019] [Accepted: 04/09/2019] [Indexed: 12/29/2022]
Abstract
The gut is the site of digestion and absorption as well as serving as an endocrine and immune organ. All of these functions may be affected by critical illness. This review will discuss secondary effects of critical illness on the gut in terms of gastrointestinal function that is clinically observable and discuss consequences of gut dysfunction with critical illness to patient outcome. Because there is little evidence-based medicine in the veterinary field, much of our understanding of gut dysfunction with critical illness comes from animal models or from the human medical field. We can extrapolate some of these conclusions and recommendations to companion animals, particularly in dogs, who have similar gastrointestinal physiology to people. Additionally, the evidence regarding gut dysfunction in veterinary patients will be explored. By recognizing signs of dysfunction early and taking preventative measures, we may be able to increase success with treatment of critical illnesses.
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Affiliation(s)
- Tracy L Hill
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, The University of Georgia, Athens, GA, USA.
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The Acute Influence of Acid Suppression with Esomeprazole on Gastrointestinal Microbiota and Brain Gene Expression Profiles in a Murine Model of Restraint Stress. Neuroscience 2019; 398:206-217. [DOI: 10.1016/j.neuroscience.2018.11.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 11/28/2018] [Accepted: 11/29/2018] [Indexed: 12/17/2022]
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11
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Barbateskovic M, Marker S, Granholm A, Anthon CT, Krag M, Jakobsen JC, Perner A, Wetterslev J, Møller MH. Stress ulcer prophylaxis with proton pump inhibitors or histamin-2 receptor antagonists in adult intensive care patients: a systematic review with meta-analysis and trial sequential analysis. Intensive Care Med 2019; 45:143-158. [PMID: 30680444 DOI: 10.1007/s00134-019-05526-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 01/07/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE Most intensive care unit (ICU) patients receive stress ulcer prophylaxis. We present updated evidence on the effects of prophylactic proton pump inhibitors (PPIs) or histamine 2 receptor antagonists (H2RAs) versus placebo/no prophylaxis on patient-important outcomes in adult ICU patients. METHODS We conducted a systematic review with meta-analysis and trial sequential analysis (TSA) of randomised clinical trials assessing the effects of PPI/H2RA versus placebo/no prophylaxis on mortality, gastrointestinal (GI) bleeding, serious adverse events (SAEs), health-related quality of life (HRQoL), myocardial ischemia, pneumonia, and Clostridium (Cl.) difficile enteritis in ICU patients. RESULTS We identified 42 trials randomising 6899 ICU patients; 3 had overall low risk of bias. We did not find an effect of stress ulcer prophylaxis on mortality [relative risk 1.03, 95% confidence interval (CI) 0.94-1.14; TSA-adjusted CI 0.94-1.14], but the occurrence of any GI bleeding was reduced as compared with placebo/no prophylaxis (0.60, 95% CI 0.47-0.77; TSA-adjusted CI 0.36-1.00). The conventional meta-analysis indicated that clinically important GI bleeding was reduced (RR 0.63, 95% CI 0.48-0.81), but the TSA-adjusted CI 0.35-1.13 indicated lack of firm evidence. The effects of stress ulcer prophylaxis on SAEs, HRQoL, pneumonia, myocardial ischemia and Cl. difficile enteritis are uncertain. CONCLUSIONS In this updated systematic review, we were able to refute a relative change of 20% of mortality. The occurrence of GI bleeding was reduced, but we lack firm evidence for a reduction in clinically important GI bleeding. The effects on SAEs, HRQoL, pneumonia, myocardial ischemia and Cl. difficile enteritis remain inconclusive.
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Affiliation(s)
- Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, 2100, Copenhagen, Denmark.
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Søren Marker
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anders Granholm
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Carl Thomas Anthon
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mette Krag
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, 2100, Copenhagen, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Cardiology, Holbaek Hospital, Holbaek, Denmark
| | - Anders Perner
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, 2100, Copenhagen, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Morten Hylander Møller
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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12
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Siddiqui F, Ahmed M, Abbasi S, Avula A, Siddiqui AH, Philipose J, Khan HM, Khan TMA, Deeb L, Chalhoub M. Gastrointestinal Bleeding in Patients With Acute Respiratory Distress Syndrome: A National Database Analysis. J Clin Med Res 2018; 11:42-48. [PMID: 30627277 PMCID: PMC6306132 DOI: 10.14740/jocmr3660] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 11/09/2018] [Indexed: 12/24/2022] Open
Abstract
Background The goal of our study was to determine the impact of gastrointestinal bleeding (GIB) on in-hospital outcomes among acute respiratory distress syndrome (ARDS) patients, and subsequently determine the potential risk factors for the development of GIB. Methods ARDS patients with and without GIB were identified using the National Inpatient Sample (2002 - 2012). Linear regression analysis was used to assess impact of GIB on in-hospital mortality, length of stay and total charges. Univariate logistic regression was used to determine associated odds ratios (OR) for causes of ARDS and common comorbid conditions. Results We identified 149,190 ARDS patients. The incidence of GIB was the highest among patients > 60 years (P < 0.001). GIB was associated with longer hospitalization days (7.3 days versus 11.9 days, P < 0.001), higher mortality (11% versus 27%, P < 0.001) and greater economic burden ($82,812 versus $45,951, P < 0.001). GIB was common in cirrhosis (OR: 8.3), peptic ulcer disease (OR: 3.7), coagulopathy disorders (OR: 3.003), thrombocytopenia (OR: 2.6), anemia (OR: 2.5) and atrial fibrillation (OR: 1.5). ARDS secondary to aspiration pneumonia (OR: 2.0), pancreatitis (OR: 2.0), sepsis (OR: 1.6) and community acquired pneumonia (OR: 0.8) was more likely to have GIB. Conclusion Our study demonstrates that GIB in ARDS patients is associated with significant increased mortality, hospitalization and health care cost.
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Affiliation(s)
- Faraz Siddiqui
- Department of Pulmonary & Critical Care, Staten Island University Hospital, Northwell Health, NY, USA
| | - Moiz Ahmed
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, NY, USA
| | - Saqib Abbasi
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, NY, USA
| | - Akshay Avula
- Department of Pulmonary & Critical Care, Staten Island University Hospital, Northwell Health, NY, USA
| | - Abdul Hasan Siddiqui
- Department of Pulmonary & Critical Care, Staten Island University Hospital, Northwell Health, NY, USA
| | - Jobin Philipose
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, NY, USA
| | - Hafiz M Khan
- Department of Gastroenterology and Hepatology, Staten Island University Hospital, Northwell Health, NY, USA
| | - Tahir M A Khan
- Department of Internal Medicine, Marshfield Clinic, WI, USA
| | - Liliane Deeb
- Department of Gastroenterology and Hepatology, Staten Island University Hospital, Northwell Health, NY, USA
| | - Michel Chalhoub
- Department of Pulmonary & Critical Care, Staten Island University Hospital, Northwell Health, NY, USA
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13
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Reynolds PM, MacLaren R. Re-evaluating the Utility of Stress Ulcer Prophylaxis in the Critically Ill Patient: A Clinical Scenario-Based Meta-Analysis. Pharmacotherapy 2018; 39:408-420. [PMID: 30101529 DOI: 10.1002/phar.2172] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
STUDY OBJECTIVE Because recent studies have challenged the efficacy of stress ulcer prophylaxis (SUP) in the critically ill patient, our objective was to evaluate the efficacy of SUP with proton pump inhibitors (PPIs) or histamine2 -receptor antagonists (H2 RAs) against placebo, control, no therapy, or enteral nutrition alone in critically ill adults. DESIGN Meta-analysis with trial sequential analysis (TSA) of 34 randomized controlled trials. PATIENTS A total of 3220 critically ill adults who received PPIs or H2 RAs versus placebo, control, no therapy, or enteral nutrition. MEASUREMENTS AND MAIN RESULTS A systematic review was performed using a random effects meta-analysis with TSA according to a predefined protocol. Randomized controlled trials comparing PPIs or H2 RAs with either placebo, control, no therapy, or enteral nutrition alone were identified through a comprehensive search of the literature. Two blinded reviewers independently assessed studies for inclusion, risk of bias, and extracted data using Cochrane Collaborative methodology. The predefined primary outcomes were clinically important, overt, and any (clinically important plus overt) gastrointestinal bleeding. Secondary outcomes included pneumonia, Clostridium difficile-associated diarrhea (CDAD), and mortality. Subgroup analyses were conducted for the primary outcome by PPI or H2 RA use, intensive care unit (ICU) subtype, studies published after early goal-directed therapy (EGDT), the presence of risk factors for stress ulceration, and enteral nutrition use. Of the 34 trials included, 33 were judged as high risk of bias and 1 was judged as low risk. Use of SUP significantly reduced clinically important bleeding (risk ratio [RR] 0.53, 95% confidence interval [CI] 0.37-0.76, p<0.001; I2 = 0%), overt bleeding (RR 0.55, 95% CI 0.39-0.76, p=0.0003; I2 = 53%), and any bleeding (RR 0.54, 95% CI 0.41-0.71, p<0.00001; I2 = 58%). TSA confirmed these findings. No significant differences in pneumonia, CDAD, or mortality were noted. Subgroup analyses revealed significant reductions in clinically important bleeding with SUP in neurosurgical patients (RR 0.37, p<0.05) but not in surgery/trauma or medical ICU patients with risk factors. SUP provided no benefit in studies published after EGDT. SUP significantly reduced clinically important bleeding regardless of the use of enteral nutrition (p<0.05). CONCLUSION This meta-analysis demonstrated that SUP use was associated with significant reductions in bleeding but not mortality. SUP should not be abandoned until large randomized trials demonstrate the futility of this intervention.
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Affiliation(s)
- Paul M Reynolds
- University of Colorado Skaggs School of Pharmacy, Aurora, Colorado
| | - Robert MacLaren
- University of Colorado Skaggs School of Pharmacy, Aurora, Colorado
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14
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Barbateskovic M, Marker S, Jakobsen JC, Krag M, Granholm A, Anthon CT, Perner A, Wetterslev J, Møller MH. Stress ulcer prophylaxis in adult intensive care unit patients - a protocol for a systematic review. Acta Anaesthesiol Scand 2018; 62:744-755. [PMID: 29577238 DOI: 10.1111/aas.13109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 02/25/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND In the intensive care unit (ICU), stress ulcer prophylaxis with proton pump inhibitors or histamine-2-receptor antagonists is standard of care although gastrointestinal bleeding remains uncommon. It remains unknown whether its use is associated with benefits or harms and the quality of evidence supporting the use of stress ulcer prophylaxis has been questioned. Accordingly, the objective of this systematic review was to critically assess the evidence from randomized clinical trials on the benefits and harms of stress ulcer prophylaxis vs. placebo or no prophylaxis in adult ICU patients. METHODS We will systematically search for randomized clinical trials in major international databases. Two authors will independently screen and select trials for inclusion, extract data and assess the methodological quality using the Cochrane risk of bias tool. Any disagreement will be resolved by consensus. We will perform conventional meta-analyses using Review Manager, and STATA 15, and we will assess the risk of random errors using Trial Sequential Analysis. Also, we will assess and report the overall quality of evidence for all outcomes according to GRADE. DISCUSSION The evidence on the benefits and harms of stress ulcer prophylaxis in adult ICU patients is unclear and an updated systematic review is warranted as new trials have been published. To control risks of systematic and random errors, we will use Cochrane and GRADE methodology and Trial Sequential Analysis. Our ambition with this systematic review is to provide updated, reliable and precise data to better inform decision makers on the use of stress ulcer prophylaxis in adult ICU patients.
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Affiliation(s)
- M. Barbateskovic
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen Denmark
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - S. Marker
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - J. C. Jakobsen
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen Denmark
- Department of Cardiology; Holbaek Hospital; Holbaek Denmark
| | - M. Krag
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - A. Granholm
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - C. T. Anthon
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - A. Perner
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - J. Wetterslev
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen Denmark
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - M. H. Møller
- Centre for Research in Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
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15
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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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16
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Hill TL, Lascelles BDX, Blikslager AT. Effect of sucralfate on gastric permeability in an ex vivo model of stress-related mucosal disease in dogs. J Vet Intern Med 2018; 32:670-678. [PMID: 29460464 PMCID: PMC5866966 DOI: 10.1111/jvim.15076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 11/19/2017] [Accepted: 01/22/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Sucralfate is a gastroprotectant with no known systemic effects. The efficacy of sucralfate for prevention and treatment of stress-related mucosal diseases (SRMD) in dogs is unknown. HYPOTHESIS/OBJECTIVES To develop a canine ex vivo model of SRMD and to determine the effect of sucralfate on mucosal barrier function in this model. ANIMALS Gastric antral mucosa was collected immediately postmortem from 29 random-source apparently healthy dogs euthanized at a local animal control facility. METHODS Randomized experimental trial. Sucralfate (100 mg/mL) was applied to ex vivo canine gastric mucosa concurrent with and after acid injury. Barrier function was assessed by measurement of transepithelial electrical resistance (TER) and radiolabeled mannitol flux. RESULTS Application of acidified Ringers solution to the mucosal side of gastric antrum caused a reduction in gastric barrier function, and washout of acidified Ringers solution allowed recovery of barrier function (TER: 34.0 ± 2.8% of control at maximum injury, 71.3 ± 5.5% at recovery, P < .001). Sucralfate application at the time of injury or after injury significantly hastened recovery of barrier function (TER: 118.0 ± 15.2% of control at maximum injury, P < .001 and 111.0 ± 15.5% at recovery, P = .35). CONCLUSIONS AND CLINICAL IMPORTANCE Sucralfate appeared effective at restoring defects in gastric barrier function induced by acid and accelerating repair of tissues subjected to acid in this model, suggesting that sucralfate could have utility for the treatment and prevention of SRMD in dogs.
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Affiliation(s)
- Tracy L. Hill
- Department of Small Animal Medicine and Surgery, College of Veterinary MedicineUniversity of GeorgiaAthensGeorgia
| | - B. Duncan X. Lascelles
- Department of Clinical Sciences, College of Veterinary MedicineNorth Carolina State UniversityRaleighNorth Carolina
- Center for Pain Research and InnovationUNC School of DentistryChapel HillNorth Carolina
- Department of Anesthesiology, Center for Translational Pain ResearchDuke UniversityDurhamNorth Carolina
| | - Anthony T. Blikslager
- Department of Clinical Sciences, College of Veterinary MedicineNorth Carolina State UniversityRaleighNorth Carolina
- Center for Gastrointestinal Biology and Disease, Large Animal Models CoreNorth Carolina State UniversityRaleighNorth Carolina
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17
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Alhazzani W, Alshamsi F, Belley-Cote E, Heels-Ansdell D, Brignardello-Petersen R, Alquraini M, Perner A, Møller MH, Krag M, Almenawer S, Rochwerg B, Dionne J, Jaeschke R, Alshahrani M, Deane A, Perri D, Thebane L, Al-Omari A, Finfer S, Cook D, Guyatt G. Efficacy and safety of stress ulcer prophylaxis in critically ill patients: a network meta-analysis of randomized trials. Intensive Care Med 2017; 44:1-11. [PMID: 29199388 PMCID: PMC5770505 DOI: 10.1007/s00134-017-5005-8] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 11/24/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE Stress ulcer prophylaxis (SUP) is commonly prescribed in the intensive care unit. However, data from systematic reviews and conventional meta-analyses are limited by imprecision and restricted to direct comparisons. We conducted a network meta-analysis of randomized clinical trials (RCTs) to examine the safety and efficacy of drugs available for SUP in critically ill patients. METHODS We searched MEDLINE, EMBASE, and the Cochrane Library Central Register of Controlled Trials through April 2017 for randomized controlled trials that examined the efficacy and safety of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), and sucralfate for SUP in critically ill patients. No date or language restrictions were applied. Data on study characteristics, methods, outcomes, and risk of bias were abstracted by two reviewers. RESULTS Of 96 potentially eligible studies, we included 57 trials enrolling 7293 patients. The results showed that PPIs are probably more effective for preventing clinically important gastrointestinal bleeding (CIB) than H2RAs [odds ratio (OR) 0.38; 95% confidence interval (95% CI) 0.20, 0.73], sucralfate (OR 0.30; 95% CI 0.13, 0.69), and placebo (OR 0.24; 95% CI 0.10, 0.60) (all moderate quality evidence). There were no convincing differences among H2RA, sucralfate, and placebo. PPIs probably increase the risk of developing pneumonia compared with H2RAs (OR 1.27; 95% CI 0.96, 1.68), sucralfate (OR 1.65; 95% CI 1.20, 2.27), and placebo (OR 1.52; 95% CI 0.95, 2.42) (all moderate quality). Mortality is probably similar across interventions (moderate quality). Estimates of baseline risks of bleeding varied significantly across studies, and only one study reported on Clostridium difficile infection. Definitions of pneumonia varied considerably. Most studies on sucralfate predate pneumonia prevention strategies. CONCLUSIONS Our results provide moderate quality evidence that PPIs are the most effective agents in preventing CIB, but they may increase the risk of pneumonia. The balance of benefits and harms leaves the routine use of SUP open to question.
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Affiliation(s)
- Waleed Alhazzani
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada. .,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, UAE University, Al Ain, United Arab Emirates
| | - Emilie Belley-Cote
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | | | - Mustafa Alquraini
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Mette Krag
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Saleh Almenawer
- Department of Surgery, McMaster University, Hamilton, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Joanna Dionne
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada
| | - Roman Jaeschke
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | | | - Adam Deane
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Dan Perri
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada
| | - Lehana Thebane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Awad Al-Omari
- Department of Critical Care, Security Forces Hospital, Riyadh, Saudi Arabia.,Department of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Simon Finfer
- The George Institute for Global Health and Royal North Shore Hospital, University of Sydney, Sydney, NSW, Australia
| | - Deborah Cook
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Gordon Guyatt
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
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Marker S, Perner A, Wetterslev J, Barbateskovic M, Jakobsen JC, Krag M, Granholm A, Anthon CT, Møller MH. Stress ulcer prophylaxis versus placebo or no prophylaxis in adult hospitalised acutely ill patients-protocol for a systematic review with meta-analysis and trial sequential analysis. Syst Rev 2017; 6:118. [PMID: 28646925 PMCID: PMC5483291 DOI: 10.1186/s13643-017-0509-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Stress ulcer prophylaxis is considered standard of care in many critically ill patients in the intensive care unit (ICU). However, the quality of evidence supporting this has recently been questioned, and clinical equipoise exists. Whether there is overall benefit or harm of stress ulcer prophylaxis in adult hospitalised acutely ill patients is unknown. Accordingly, we aim to assess patient-important benefits and harms of stress ulcer prophylaxis versus placebo or no treatment in adult hospitalised acutely ill patients with high risk of gastrointestinal bleeding irrespective of hospital setting. METHODS/DESIGN We will conduct a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis and assess use of proton pump inhibitors (PPIs) or histamine-2-receptor antagonists (H2RAs) in any dose, formulation and duration. We will accept placebo or no prophylaxis as control interventions. The participants will be adult hospitalised acutely ill patients with high risk of gastrointestinal bleeding. We will systematically search the Cochrane Library, MEDLINE, EMBASE, Science Citation Index, BIOSIS and Epistemonikos for relevant literature. We will follow the recommendations by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. The risk of systematic errors (bias) and random errors will be assessed, and the overall quality of evidence will be evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. DISCUSSION There is a need for a high-quality systematic review to summarise the benefits and harms of stress ulcer prophylaxis in hospitalised patients to inform practice and future research. Although stress ulcer prophylaxis is used worldwide, no firm evidence for benefit or harm as compared to placebo or no treatments has been established. Critical illness is a continuum not limited to the ICU setting, which is why it is important to assess the benefits and harms of stress ulcer prophylaxis in a wider perspective than exclusively in ICU patients. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017055676.
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Affiliation(s)
- Søren Marker
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark. .,Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark.
| | - Anders Perner
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark.,Department of Cardiology, Holbaek Hospital, Holbaek, Denmark
| | - Mette Krag
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Anders Granholm
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Carl Thomas Anthon
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
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Ovenden C, Plummer MP, Selvanderan S, Donaldson TA, Nguyen NQ, Weinel LM, Finnis ME, Summers MJ, Ali Abdelhamid Y, Chapman MJ, Rayner CK, Deane AM. Occult upper gastrointestinal mucosal abnormalities in critically ill patients. Acta Anaesthesiol Scand 2017; 61:216-223. [PMID: 27966213 DOI: 10.1111/aas.12844] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/18/2016] [Accepted: 11/15/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND The objectives of this study were to estimate the frequency of occult upper gastrointestinal abnormalities, presence of gastric acid as a contributing factor, and associations with clinical outcomes. METHODS Data were extracted for study participants at a single centre who had an endoscopy performed purely for research purposes and in whom treating physicians were not suspecting gastrointestinal bleeding. Endoscopic data were independently adjudicated by two gastroenterologists who rated the likelihood that observed pathological abnormalities were related to gastric acid secretion using a 3-point ordinal scale (unlikely, possible or probable). RESULTS Endoscopy reports were extracted for 74 patients [age 52 (37, 65) years] undergoing endoscopy on day 5 [3, 9] of ICU admission. Abnormalities were found in 25 (34%) subjects: gastritis/erosions in 10 (14%), nasogastric tube trauma in 8 (11%), oesophagitis in 4 (5%) and non-bleeding duodenal ulceration in 3 (4%). The contribution of acid secretion to observed pathology was rated 'probable' in six subjects (rater #1) and five subjects (rater #2). Prior to endoscopy, 39 (53%) patients were receiving acid-suppressive therapy. The use of acid-suppressive therapy was not associated with the presence of an endoscopic abnormality (present 15/25 (60%) vs. absent 24/49 (49%); P = 0.46). Haemoglobin concentrations, packed red cells transfused and mortality were not associated with mucosal abnormalities (P = 0.83, P > 0.9 and P > 0.9 respectively). CONCLUSIONS Occult mucosal abnormalities were observed in one-third of subjects. The presence of mucosal abnormalities appeared to be independent of prior acid-suppressive therapy and was not associated with reduced haemoglobin concentrations, increased transfusion requirements, or mortality.
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Affiliation(s)
- C. Ovenden
- Discipline of Acute Care Medicine; University of Adelaide; Adelaide SA Australia
| | - M. P. Plummer
- Discipline of Acute Care Medicine; University of Adelaide; Adelaide SA Australia
- Neurosciences Critical Care Unit; Addenbrooke's Hospital; Cambridge UK
| | - S. Selvanderan
- Discipline of Acute Care Medicine; University of Adelaide; Adelaide SA Australia
| | - T. A. Donaldson
- Department of Anaesthesia; Royal Adelaide Hospital; Adelaide SA Australia
| | - N. Q. Nguyen
- Centre for Research Excellence in Translating Nutritional Science to Good Health; Adelaide SA Australia
- Discipline of Medicine; University of Adelaide; Adelaide SA Australia
- Department of Gastroenterology and Hepatology; Royal Adelaide Hospital; Adelaide SA Australia
| | - L. M. Weinel
- Department of Critical Care Services; Royal Adelaide Hospital; Adelaide SA Australia
| | - M. E. Finnis
- Discipline of Acute Care Medicine; University of Adelaide; Adelaide SA Australia
- Department of Critical Care Services; Royal Adelaide Hospital; Adelaide SA Australia
| | - M. J. Summers
- Department of Critical Care Services; Royal Adelaide Hospital; Adelaide SA Australia
| | - Y. Ali Abdelhamid
- Discipline of Acute Care Medicine; University of Adelaide; Adelaide SA Australia
| | - M. J. Chapman
- Discipline of Acute Care Medicine; University of Adelaide; Adelaide SA Australia
- Centre for Research Excellence in Translating Nutritional Science to Good Health; Adelaide SA Australia
- Department of Critical Care Services; Royal Adelaide Hospital; Adelaide SA Australia
| | - C. K. Rayner
- Centre for Research Excellence in Translating Nutritional Science to Good Health; Adelaide SA Australia
- Discipline of Medicine; University of Adelaide; Adelaide SA Australia
- Department of Gastroenterology and Hepatology; Royal Adelaide Hospital; Adelaide SA Australia
| | - A. M. Deane
- Discipline of Acute Care Medicine; University of Adelaide; Adelaide SA Australia
- Department of Critical Care Services; Royal Adelaide Hospital; Adelaide SA Australia
- Intensive Care Unit; The Royal Melbourne Hospital; Parkville Vic. Australia
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20
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Abstract
PURPOSE OF REVIEW Stress ulcer prophylaxis (SUP) is considered standard of care in the majority of critically ill patients in the ICU. In this review, we will present the current evidence for the use of SUP in ICU patients, including data on the prevalence of gastrointestinal bleeding and the balance between benefits and harms of SUP. RECENT FINDINGS The prevalence of overt gastrointestinal bleeding in critically ill patients is in the area of 5%. Consistent risk factors for gastrointestinal bleeding have been identified, but indications for SUP vary considerably. SUP is used in three out of four critically ill patients, most frequently in the form of proton pump inhibitors. A recent systematic review of SUP vs. placebo or no prophylaxis in critically ill patients highlights the lack of evidence supporting the use of SUP. Importantly, data suggest potential harm, including increased risk of nosocomial infections and cardiovascular events. SUMMARY The prevalence of gastrointestinal bleeding in critically ill patients in the ICU is low, the prognostic importance is ambiguous, and SUP is widely used. The balance between benefits and harms of SUP is unknown, and clinical equipoise exists. High-quality randomized controlled trials and systematic reviews assessing benefits and harms of SUP in ICU patients are highly warranted.
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21
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Kaplan MM, May JR. The Influence of pH Control on the Prevention and Management of Gastrointestinal Bleeding. J Intensive Care Med 2016. [DOI: 10.1177/0885066690005001s06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Gastrointestinal bleeding from stress-related mucosal damage (SRMD) is caused by a breakdown in the pro cesses that normally protect the gastric mucosa from the corrosive effects of gastric acid and the proteolytic enzyme pepsin. Prostaglandins stimulate some of these protective factors, which include mucus secretion, bi carbonate secretion, rapid cellular repair and rapid blood flow. Acid and pepsin inhibit blood clotting in the stomach by inhibiting platelet aggregation and the func tion of all of the blood clotting factors. The inhibition of blood clotting in the stomach exacerbates bleeding caused by ulcers in the stomach and duodenum. Hence, treatment that will raise intragastric pH (lower acid con centration) should be effective in preventing gastric bleeding from SRMD. Patients in intensive care units are at high risk of developing upper gastrointestinal bleed ing from SRMD. It is easier to prevent SRMD bleeding than to treat it once it starts. Hence, patients in intensive care units should be treated prophylactically to prevent bleeding. Controlled trials and clinical experience indi cate that both antacids and H2 blockers in doses high enough to raise the intragastric pH above 4 are effective forms of prophylaxis. Intravenously administered H2 blockers are more convenient to administer and have fewer side effects than the large doses of antacid re quired to maintain the intragastric pH above 4.
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Affiliation(s)
- Marshall M. Kaplan
- Division of Gastroenterology, New England Medical Center,
Tufts University School of Medicine, Boston, MA
| | - J. Russell May
- Pharmacy for Drug Information and Clinical Services,
The Medical College of Georgia, Augusta, GA
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22
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Abstract
The mortality associated with bleeding stress ulcers in patients in intensive care units exceeds 50%. Iden tification of patients at risk and use of early and effec tive prophylaxis are necessary in the management of patients in intensive care units. The use of antacids is inconvenient, expensive, and associated with electro lyte disturbances and erratic pH control. H2-receptor antagonists are the preferred agents for stress ulcer pro phylaxis because of their proven efficacy, safety, and ease of administration. Adjunct therapy with cyto protective agents may be useful in patients with com promised mucosal defences.
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Affiliation(s)
- Edgar R. Gonzalez
- Department of Pharmacy and Pharmaceutics and the Department
of Internal Medicine, Medical College of Virginia, Richmond, VA
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23
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Moore J. The Antisecretory Effects of Ranitidine Administered by Continuous Infusion. J Intensive Care Med 2016. [DOI: 10.1177/0885066690005001s07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Prevention of stress-induced upper gastrointestinal ul ceration and bleeding is an important issue for clinicians caring for critically ill patients. Although H2 blockers have been demonstrated as effective in treating patients with stress ulcers and bleeding, the ideal regimen of administration has not yet been devised. One method, continuous intravenous infusion, minimizes variation in drug effects by controlling for pharmacokinetic vari ables. Even with the use of continuous infusion, consis tent control of gastric pH may not be attained. Because of the pharmacokinetic, pharmacodynamic, and patient variables, there is often a discrepancy between H2 blocker dose and effects. Studies in healthy persons and patients with duodenal ulcers demonstrate a circadian variation in gastric acid production and in the effects of H2 blockers on gastric pH. In particular, H2 blockers may be less effective in the evening. To address this concern in intensive care patients, continuous intrave nous infusions of H2 blockers can be used, but variable rates of intravenous infusions may be more effective, allowing for the circadian variations in gastric acidity. Further study is needed to define patient groups that most require intravenous H2 blockers, to devise regi mens that are more effective in continuously controlling gastric pH in critically ill patients, and to clarify dose- response relationships for H2 blockers.
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Affiliation(s)
- John Moore
- Department of Medicine, Veterans Administration Medical
Center, Salt Lake City, UT
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24
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Reilly J, Fennerty MB. Stress Ulcer Prophylaxis: The Prevention of Gastrointestinal Bleeding and the Development of Nosocomial Infections in Critically Ill Patients. J Pharm Pract 2016. [DOI: 10.1177/089719009801100603] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
| | - M. Brian Fennerty
- Section Chief of Gastroenterology, Oregon Health Sciences University, Portland, Oregon
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25
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Bresalier RS. Prophylaxis of Stress-related Gastric Mucosal Hemorrhage: A Critical Appraisal. J Intensive Care Med 2016. [DOI: 10.1177/088506669000500103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Robert S. Bresalier
- University of California, San Francisco and Veterans Administration Medical Center San Francisco, CA 94121
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26
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Karlstadt RG, Iberti TJ, Silverstein J, Lindenberg L, Rright-Asare P, Rockhold F, Young MD. Comparison of Cimetidine and Placebo for the Prophylaxis of Upper Gastrointestinal Bleeding Due to Stress-related Gastric Mucosal Damage in the Intensive Care Unit. J Intensive Care Med 2016. [DOI: 10.1177/088506669000500106] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A multicenter, randomized, double-blind, placebo- controlled study was conducted with 87 patients in in tensive care units to study the effectiveness of constant infusions of cimetidine (50 mg/hr) in the prophylaxis of stress-related mucosal bleeding. Fifty-four patients re ceived cimetidine and 33 received placebo. The groups were comparable by age, sex, and severity of illness. One (2%) of the 54 patients receiving cimetidine had upper gastrointestinal hemorrhage and 7 (21%) of the 33 patients receiving placebo had upper gastrointestinal hemorrhage (p = 0.002). The risk of bleeding for every 100 patient days in intensive care units was reduced by 94% in the patients receiving cimetidine. Constant infu sion cimetidine was well tolerated. Only one patient (cimetidine) developed pneumonia during the study, but it was not considered to be related to drug therapy. No patients experienced adverse drug interactions. Two patients (4%) experienced reversible side effects from treatment. Cimetidine, administered as a continuous in travenous 50-mg/hour infusion, is safe and significantly more effective than placebo for preventing upper gas trointestinal bleeding in critically ill patients.
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27
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Abstract
Stress ulcer syndrome refers to gastroduodenal erosions or ulcers that develop acutely in relation to major physi ological stress, usually manifested clinically as upper gastrointestinal (UGI) bleeding. These lesions occur most often in the gastric fundus. Endoscopy has shown gastroduodenal mucosal lesions in 75 to 100% of inten sive care unit (ICU) patients within 72 hours of admis sion. Patients at high risk for stress ulcer include those with large body surface area burns, intracranial lesions associated with coma, fulminant hepatic failure, sepsis, and trauma and abdominal, cardiovascular, and thoracic surgery patients. Also considered high risk are ICU pa tients with superimposed complications such as shock, mechanical ventilation for more than 3 days, coagulopa thy, jaundice, and sepsis. Approximately 15% of ICU pa tients will experience UGI bleeding from stress ulcer. Patients bleeding from stress ulcer have an overall mor tality rate approaching 65% compared with 9 to 22% mortality in patients without stress ulcer. When strati fied according to occult blood loss versus clinically significant bleeding, mortality can be as high as 90% in patients overtly bleeding; 30% of deaths are directly related to bleeding. Both antacids and H2 receptor an tagonists are effective in prophylaxis for stress ulcer bleeding.
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Affiliation(s)
| | - David Cort
- Washington University School of Medicine, St. Louis, MO
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28
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Heyman SJ, Rinaldo JE. Multiple System Organ Failure in the Adult Respiratory Distress Syndrome. J Intensive Care Med 2016. [DOI: 10.1177/088506668900400503] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Recently completed studies suggest that patients with the adult respiratory distress syndrome (ARDS) manifest early evidence of multiple-site endothelial injury. Ex trapulmonary disease is usually the cause of death in these patients. Furthermore, prognosis in individual cases of ARDS is strongly influenced by specific organ failures (e.g., hepatic and renal failure). The mechanisms by which ARDS and extrapulmonary organ system fail ure interact, however, are poorly delineated. We ad dress three aspects of the multisystemic nature of ARDS. First, we analyze evidence that suggests ARDS is a mul tisystem disorder fron the outset, involving panendothe lial injury mediated by cellular interactions and humoral substances that act similarly at many vascular target sites. Second, we discuss the role of three extrapulmo nary organs in the modulation of ARDS: the liver, the gastrointestinal mucosa, and the kidneys. Third, we ad dress the unifying hypothesis that uncontrolled ongoing inflammation, which is often but not always caused by infection, is the essential link between ARDS and its progression to multiple system organ failure.
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Affiliation(s)
- Stephen J. Heyman
- Center for Lung Research, Vanderbilt University, and the Nashville Veterans Administration Medical Center, Nashville, TN
| | - Jean E. Rinaldo
- Center for Lung Research, Vanderbilt University, and the Nashville Veterans Administration Medical Center, Nashville, TN
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29
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Abstract
In general, the histamine type-2 receptor antagonists (H2RA) enjoy an enviable record of safety. These agents, notably cimetidine, have been studied extensively in clinical trials, case reports, and worldwide drug use reporting systems. Of the available agents (cimetidine, famotidine, nizatidine, and ranitidine) several similarities exist from compound to compound and use data to support that each of the agents is equally safe and efficacious in equipotent dosing. A review of H2RA pharmacology, pharmacokinetics, adverse effects, and drug interactions is included to provide the clinician with a basis for rational selection and use of an H2RA.
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Affiliation(s)
- Edward J. Drea
- Department of Pharmacy Services, Memorial Medical Center, Springfield, IL
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30
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Intensive Care Management of Patient After Cytoreductive Surgery and HIPEC - A Concise Review. Indian J Surg Oncol 2016. [PMID: 27065716 DOI: 10.1007/s13193- 016-0511-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Hyperthermic intraperitoneal chemotherapy (HIPEC) in combination with cytoreductive surgery is a targeted treatment approach in which tumors that have spread through the lining of the abdomen are removed and then heated chemotherapy is perfused throughout the abdomen, with the intent of killing any remaining cancer cells that may be present after all the visible disease has been removed surgically. The chemotherapy is administered in high dosages to the targeted area and washed out, thereby limiting the systemic toxicity. The procedure usually takes 8 to 18 h and is most commonly used to treat appendiceal, colorectal or mesothelioma tumors including those that have failed standard chemotherapy and/or prior surgeries. Patients face major and life threatening derangements of their hemodynamic, respiratory and metabolic physiologic balance during the surgery and in the immediate postoperative period. Intensive monitoring and timely detection of possible complications and appropriate remedial action is crucial for better surgical results.
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31
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Intensive Care Management of Patient After Cytoreductive Surgery and HIPEC - A Concise Review. Indian J Surg Oncol 2016; 7:244-8. [PMID: 27065716 DOI: 10.1007/s13193-016-0511-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 02/12/2016] [Indexed: 12/21/2022] Open
Abstract
Hyperthermic intraperitoneal chemotherapy (HIPEC) in combination with cytoreductive surgery is a targeted treatment approach in which tumors that have spread through the lining of the abdomen are removed and then heated chemotherapy is perfused throughout the abdomen, with the intent of killing any remaining cancer cells that may be present after all the visible disease has been removed surgically. The chemotherapy is administered in high dosages to the targeted area and washed out, thereby limiting the systemic toxicity. The procedure usually takes 8 to 18 h and is most commonly used to treat appendiceal, colorectal or mesothelioma tumors including those that have failed standard chemotherapy and/or prior surgeries. Patients face major and life threatening derangements of their hemodynamic, respiratory and metabolic physiologic balance during the surgery and in the immediate postoperative period. Intensive monitoring and timely detection of possible complications and appropriate remedial action is crucial for better surgical results.
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Bardou M, Quenot JP, Barkun A. Stress-related mucosal disease in the critically ill patient. Nat Rev Gastroenterol Hepatol 2015; 12:98-107. [PMID: 25560847 DOI: 10.1038/nrgastro.2014.235] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Bleeding from stress-related mucosal disease in critically ill patients remains an important clinical management issue. Although only a small proportion (1-6%) of patients admitted to an intensive care unit (ICU) will bleed, a substantial proportion exhibit clinical risk factors (mechanical ventilation for >48 h and a coagulopathy) that predict an increased risk of bleeding. Furthermore, upper gastrointestinal mucosal lesions can be found in 75-100% of patients in ICUs. Although uncommon, stress-ulcer bleeding is a severe complication with an estimated mortality of 40-50%, mostly from decompensating an underlying condition or multiorgan failure. Although the vast majority of patients in ICUs receive stress-ulcer prophylaxis, largely with PPIs, some controversy surrounds their efficacy and safety. Indeed, no single trial has shown that stress-ulcer prophylaxis reduces mortality. Some reports suggest that the use of PPIs increases the risk of nosocomial infections. However, several meta-analyses and cost-effectiveness studies suggest PPIs to be more clinically effective and cost-effective than histamine-2 receptor antagonists, without considerable increases in nosocomial pneumonia. To help clinicians use the most appropriate strategy for treatment of patients in the ICU, this Review presents the latest information on all aspects of stress-related mucosal disease.
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Affiliation(s)
- Marc Bardou
- Gastroenterology and Hepatology Department, CHU de Dijon, France, 14 Rue Gaffarel BP77908, 21079 Dijon Cedex, France
| | - Jean-Pierre Quenot
- Medical Intensive Care Unit, CHU de Dijon, France, 14 Rue Gaffarel BP77908, 21079 Dijon Cedex, France
| | - Alan Barkun
- Gastroenterology Department, McGill University Health Centre, Montreal General Hospital Site, Room D7-346, 1650 Cedar Avenue, Montréal, QC H3G 1A4, Canada
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33
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Boltin D, Niv Y. Pharmacological and alimentary alteration of the gastric barrier. Best Pract Res Clin Gastroenterol 2014; 28:981-94. [PMID: 25439065 DOI: 10.1016/j.bpg.2014.09.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 07/28/2014] [Accepted: 09/15/2014] [Indexed: 02/07/2023]
Abstract
The gastric barrier contains several lines of defence which protect the epithelium from harmful microbes and toxins. Pre-mucosal defence mechanisms include secreted acid (HCl 0.1 mmol/L) and pepsin, which are capable of denaturing tissue. A tightly adherent mucous layer provides the next line of defence, and physically separates any potentially hazardous substance in the lumen from the mucosal surface. Apical secretion of HCO3(-) maintains a non-acidic microenvironment at the mucosal surface. Membrane-bound phospholipids repel soluble toxins, and sulphydryls scavenge reactive oxygen species. However, when noxious agents overwhelm these mechanisms, the epithelium is damaged. Herein, we discuss the pathological and physiological basis for several disease states which are associated with a breakdown in one or more components of the gastric barrier, including: Helicobacter pylori-associated gastritis, atrophic gastritis, stress-related mucosal disease, age-related gastropathy and portal hypertensive gastropathy. The effect of non-steroidal anti-inflammatory drugs and proton pump inhibitors on the gastric mucosa, is explored. Finally, we outline the alterations in mucosal defence caused by alcohol, caffeine, minerals and vitamins.
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Affiliation(s)
- Doron Boltin
- Department of Gastroenterology, Rabin Medical Center, Israel; The Sackler Faculty of Medicine, Tel Aviv University, Israel.
| | - Yaron Niv
- Department of Gastroenterology, Rabin Medical Center, Israel; The Sackler Faculty of Medicine, Tel Aviv University, Israel
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Cost-effectiveness of histamine receptor-2 antagonist versus proton pump inhibitor for stress ulcer prophylaxis in critically ill patients*. Crit Care Med 2014; 42:809-15. [PMID: 24365863 DOI: 10.1097/ccm.0000000000000032] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To examine the cost-effectiveness of using histamine receptor-2 antagonist or proton pump inhibitor for stress ulcer prophylaxis. DESIGN Decision analysis model examining costs and effectiveness of using histamine receptor-2 antagonist or proton pump inhibitor for stress ulcer prophylaxis. Costs were expressed in 2012 U.S. dollars from the perspective of the institution and included drug regimens and the following outcomes: clinically significant stress-related mucosal bleed, ventilator-associated pneumonia, and Clostridium difficile infection. Effectiveness was the mortality risk associated with these outcomes and represented by survival. Costs, occurrence rates, and mortality probabilities were extracted from published data. SETTING A simulation model. PATIENTS A mixed adult ICU population. INTERVENTIONS Histamine receptor-2 antagonist or proton pump inhibitor for 9 days of stress ulcer prophylaxis therapy. MAIN MEASUREMENTS AND RESULTS Output variables were expected costs, expected survival rates, incremental cost, and incremental survival rate. Univariate sensitivity analyses were conducted to determine the drivers of incremental cost and incremental survival. Probabilistic sensitivity analysis was conducted using second-order Monte Carlo simulation. For the base case analysis, the expected cost of providing stress ulcer prophylaxis was $6,707 with histamine receptor-2 antagonist and $7,802 with proton pump inhibitor, resulting in a cost saving of $1,095 with histamine receptor-2 antagonist. The associated mortality probabilities were 3.819% and 3.825%, respectively, resulting in an absolute survival benefit of 0.006% with histamine receptor-2 antagonist. The primary drivers of incremental cost and survival were the assumptions surrounding ventilator-associated pneumonia and bleed. The probabilities that histamine receptor-2 antagonist was less costly and provided favorable survival were 89.4% and 55.7%, respectively. A secondary analysis assuming equal rates of C. difficile infection showed a cost saving of $908 with histamine receptor-2 antagonists, but the survival benefit of 0.0167% favored proton pump inhibitors. CONCLUSIONS Histamine receptor-2 antagonist therapy appears to reduce costs with survival benefit comparable to proton pump inhibitor therapy for stress ulcer prophylaxis. Ventilator-associated pneumonia and bleed are the variables most affecting these outcomes. The uncertainty in the findings justifies a prospective trial.
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35
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Krag M, Perner A, Wetterslev J, Wise MP, Hylander Møller M. Stress ulcer prophylaxis versus placebo or no prophylaxis in critically ill patients. A systematic review of randomised clinical trials with meta-analysis and trial sequential analysis. Intensive Care Med 2013; 40:11-22. [PMID: 24141808 DOI: 10.1007/s00134-013-3125-3] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 09/25/2013] [Indexed: 12/15/2022]
Abstract
PURPOSE To assess the effects of stress ulcer prophylaxis (SUP) versus placebo or no prophylaxis on all-cause mortality, gastrointestinal (GI) bleeding and hospital-acquired pneumonia in adult critically ill patients in the intensive care unit (ICU). METHODS We performed a systematic review using meta-analysis and trial sequential analysis (TSA). Eligible trials were randomised clinical trials comparing proton pump inhibitors or histamine 2 receptor antagonists with either placebo or no prophylaxis. Two reviewers independently assessed studies for inclusion and extracted data. The Cochrane Collaboration methodology was used. Risk ratios/relative risks (RR) with 95% confidence intervals (CI) were estimated. The predefined outcome measures were all-cause mortality, GI bleeding, and hospital-acquired pneumonia. RESULTS Twenty trials (n = 1,971) were included; all were judged as having a high risk of bias. There was no statistically significant difference in mortality (fixed effect: RR 1.00, 95% CI 0.84-1.20; P = 0.87; I(2) = 0%) or hospital-acquired pneumonia (random effects: RR 1.23, 95% CI 0.86-1.78; P = 0.28; I(2) = 19%) between SUP patients and the no prophylaxis/placebo patients. These findings were confirmed in the TSA. With respect to GI bleeding, a statistically significant difference was found in the conventional meta-analysis (random effects: RR 0.44, 95% CI 0.28-0.68; P = 0.01; I(2) = 48%); however, TSA (TSA adjusted 95% CI 0.18-1.11) and subgroup analyses could not confirm this finding. CONCLUSIONS This systematic review using meta-analysis and TSA demonstrated that both the quality and the quantity of evidence supporting the use of SUP in adult ICU patients is low. Consequently, large randomised clinical trials are warranted.
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Affiliation(s)
- Mette Krag
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
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Nur Azlina MF, Kamisah Y, Chua KH, Qodriyah HMS. Tocotrienol Attenuates Stress-Induced Gastric Lesions via Activation of Prostaglandin and Upregulation of COX-1 mRNA. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2013; 2013:804796. [PMID: 23970937 PMCID: PMC3736463 DOI: 10.1155/2013/804796] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 06/25/2013] [Accepted: 07/02/2013] [Indexed: 12/23/2022]
Abstract
The present study aims to distinguish the effect of tocotrienol on an important gastric protective factor, prostaglandin E2 (PGE2), in stress-induced gastric injury. Twenty-eight Wistar rats were divided into four groups of seven rats each. Two control groups were fed commercial rat diet, and two treatment groups were fed the same diet but with additional dose of omeprazole (20 mg/kg) or tocotrienol (60 mg/kg). After 28 days, rats from one control group and both treated groups were subjected to water-immersion restraint stress for 3.5 hours once. The rats were then sacrificed, their stomach isolated and gastric juice collected, lesions examined, and gastric PGE2 content and cyclooxygenase (COX) mRNA expression were determined. Both the regimes significantly attenuated the total lesion area in the stomach compared to the control. Gastric acidity, which was increased in stress, was significantly reduced in rats supplemented with omeprazole and tocotrienol. The PGE2 content was also significantly higher in the rats given tocotrienol supplementation compared to the control followed by an increase in COX-1 mRNA expression. We conclude that tocotrienol supplementation protected rat gastric mucosa against stress-induced lesions possibly by reducing gastric acidity and preserving gastric PGE2 by increasing COX-1 mRNA.
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Affiliation(s)
- Mohd Fahami Nur Azlina
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
| | - Yusof Kamisah
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
| | - Kien Hui Chua
- Department of Physiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
| | - Hj Mohd Saad Qodriyah
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
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Mutlu GM, Mutlu EA, Factor P. Prevention and Treatment of Gastrointestinal Complications in Patients on Mechanical Ventilation. ACTA ACUST UNITED AC 2012; 2:395-411. [PMID: 14719992 DOI: 10.1007/bf03256667] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
There exists a complex, dynamic interaction between mechanical ventilation and the splanchnic vasculature that contributes to a myriad of gastrointestinal tract complications that arise during critical illness. Positive pressure-induced splanchnic hypoperfusion appears to play a pivotal role in the pathogenesis of these complications, the most prevalent of which are stress-related mucosal damage, gastrointestinal hypomotility and diarrhea. Furthermore, characteristics of the splanchnic vasculature make the gastrointestinal tract vulnerable to adverse effects related to positive pressure ventilation. While most of these complications seen in mechanically ventilated patients are reflections of altered gastrointestinal physiology, some may be attributed to medical interventions instituted to treat critical illness. Since maintenance of normal hemodynamics cannot always be achieved, pharmacologic prophylactic therapy has become a mainstay in the prevention of gastrointestinal complications in the intensive care unit. Improved understanding of the systemic effects of mechanical ventilation and greater application of lung-protective ventilatory strategies may potentially minimize positive pressure-induced reductions in splanchnic perfusion, systemic cytokine release and, consequently, reduce the incidence of gastrointestinal complications associated with mechanical ventilation. Herein, we discuss the pathophysiology of gastrointestinal complications associated with mechanical ventilation, summarize the most prevalent complications and focus on preventive strategies and available treatment options for these complications. The most common causes of gastrointestinal hemorrhage in mechanically ventilated patients are bleeding from stress-related mucosal damage and erosive esophagitis. In general, histamine H(2) receptor antagonists and proton pump inhibitors prevent stress-related mucosal disease by raising the gastric fluid pH. Proton pump inhibitors tend to provide more consistent pH control than histamine H(2) receptor antagonists. There is no consensus on the drug of choice for stress ulcer prophylaxis with several meta-analyses providing conflicting results on the superiority of any medication. Prevention of erosive esophagitis include careful use of nasogastric tubes and institution of strategies that improve gastric emptying. Many mechanically ventilated patients have gastrointestinal hypomotility and diarrhea. Treatment options for gastrointestinal motility are limited, thus, preventive measures such as correction of electrolyte abnormalities and avoidance of medications that impair gastrointestinal motility are crucial. Treatment of diarrhea depends on the underlying cause. When associated with Clostridium difficile infection antibacterial therapy should be discontinued, if possible, and treatment with oral metronidazole should be initiated.More studies are warranted to better understand the systemic effects of mechanical ventilation on the gastrointestinal tract and to investigate the impact of lung protective ventilatory strategies on gastrointestinal complications.
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Affiliation(s)
- Gökhan M Mutlu
- Division of Pulmonary and Critical Care Medicine, Evanston Northwestern Healthcare, Evanston Illinois and Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
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Frandah W, Colmer-Hamood J, Nugent K, Raj R. Patterns of Use of Prophylaxis for Stress-Related Mucosal Disease in Patients Admitted to the Intensive Care Unit. J Intensive Care Med 2012; 29:96-103. [DOI: 10.1177/0885066612453542] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background: Morbidity associated with stress ulcer–related bleeding, the cost of medications, and the possible complications associated with stress ulcer prophylaxis are important considerations when prescribing prophylaxis. We prospectively studied the prescription patterns for stress ulcer prophylaxis in patients admitted to our ICU. Methods: We prospectively recorded the indications for stress ulcer prophylaxis and prescription patterns for use based on the American Society of Healthcare Pharmacists criteria and other indications for 99 new intensive care unit (ICU) admissions to a tertiary referral center. Results: In all 51 patients had no indication for stress ulcer prophylaxis, 32 had 1 indication, 14 had 2 indications, and 2 patients had 3 indications for receiving stress ulcer prophylaxis in the ICU. Eighty-two percent of patients without any indications received stress ulcer prophylaxis; 81% of patients with 1 indication, 79% of patients with 2 indication, and 50% of patients with 3 indications received stress ulcer prophylaxis. Overall, 53% of patients either received stress ulcer prophylaxis when none was indicated or did not receive stress ulcer prophylaxis when it was indicated. We also review the recent literature on stress-related mucosal disease and the use of prophylaxis for stress-related mucosal disease. Conclusions: Stress ulcer prophylaxis administration in this ICU is inconsistent and includes both underutilization and overutilization. Educating physicians and implementing hospital protocols could improve use patterns.
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Affiliation(s)
- Wesam Frandah
- Department of Internal Medicine , Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Jane Colmer-Hamood
- Department of Microbiology, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Kenneth Nugent
- Department of Internal Medicine , Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Rishi Raj
- Department of Internal Medicine , Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Ock CY, Hong KS, Choi KS, Chung MH, Kim YS, Kim JH, Hahm KB. A novel approach for stress-induced gastritis based on paradoxical anti-oxidative and anti-inflammatory action of exogenous 8-hydroxydeoxyguanosine. Biochem Pharmacol 2011; 81:111-22. [DOI: 10.1016/j.bcp.2010.08.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Revised: 08/22/2010] [Accepted: 08/24/2010] [Indexed: 01/07/2023]
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Stress ulcer prophylaxis in the new millennium: A systematic review and meta-analysis. Crit Care Med 2010; 38:2222-8. [DOI: 10.1097/ccm.0b013e3181f17adf] [Citation(s) in RCA: 156] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Terzi Coelho CB, Dragosavac D, Coelho Neto JS, Montes CG, Guerrazzi F, Andreollo NA. Ranitidine is unable to maintain gastric pH levels above 4 in septic patients. J Crit Care 2010; 24:627.e7-13. [PMID: 19931156 DOI: 10.1016/j.jcrc.2009.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2008] [Revised: 02/23/2009] [Accepted: 02/26/2009] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Cristina B Terzi Coelho
- Intensive Care Unit, Teaching Hospital of the State University of Campinas, Campinas, São Paulo, Brazil.
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Pang SH, Graham DY. A clinical guide to using intravenous proton-pump inhibitors in reflux and peptic ulcers. Therap Adv Gastroenterol 2010; 3:11-22. [PMID: 21180586 PMCID: PMC3002568 DOI: 10.1177/1756283x09352095] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Intravenous (IV) proton-pump inhibitors (PPIs) are potent gastric acid suppressing agents, and their use is popular in clinical practice. Both IV and oral PPIs have similarly short half-lives, and their effects on acid secretion are similar, thus their dosing and dosage intervals appear to be interchangeable. The possible exception is when sustained high pHs are required to promote clot stabilization in bleeding peptic ulcers. Continuous infusion appears to be the only form of administration that reliably achieves these high target pHs. IV PPI is indicated in the treatment of high-risk peptic ulcers, complicated gastroesophageal reflux, stress-induced ulcer prophylaxis, Zollinger-Ellison syndrome, and whenever it is impossible or impractical to give oral therapy. The widespread use of PPIs has been controversial. IV PPIs have been linked to the development of nosocomial pneumonia in the intensive care setting and to spontaneous bacterial peritonitis in cirrhotic patients. This review discusses the use of IV PPI in different clinical scenarios, its controversies, and issues of appropriate use.
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Affiliation(s)
- Sandy H. Pang
- Institute of Digestive Disease, Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - David Y. Graham
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA,
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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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Laine L, Takeuchi K, Tarnawski A. Gastric mucosal defense and cytoprotection: bench to bedside. Gastroenterology 2008; 135:41-60. [PMID: 18549814 DOI: 10.1053/j.gastro.2008.05.030] [Citation(s) in RCA: 440] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Revised: 04/07/2008] [Accepted: 05/05/2008] [Indexed: 02/06/2023]
Abstract
The gastric mucosa maintains structural integrity and function despite continuous exposure to noxious factors, including 0.1 mol/L HCl and pepsin, that are capable of digesting tissue. Under normal conditions, mucosal integrity is maintained by defense mechanisms, which include preepithelial factors (mucus-bicarbonate-phospholipid "barrier"), an epithelial "barrier" (surface epithelial cells connected by tight junctions and generating bicarbonate, mucus, phospholipids, trefoil peptides, prostaglandins (PGs), and heat shock proteins), continuous cell renewal accomplished by proliferation of progenitor cells (regulated by growth factors, PGE(2) and survivin), continuous blood flow through mucosal microvessels, an endothelial "barrier," sensory innervation, and generation of PGs and nitric oxide. Mucosal injury may occur when noxious factors "overwhelm" an intact mucosal defense or when the mucosal defense is impaired. We review basic components of gastric mucosal defense and discuss conditions in which mucosal injury is directly related to impairment in mucosal defense, focusing on disorders with important clinical sequelae: nonsteroidal anti-inflammatory drug (NSAID)-associated injury, which is primarily related to inhibition of cyclooxygenase (COX)-mediated PG synthesis, and stress-related mucosal disease (SRMD), which occurs with local ischemia. The annual incidence of NSAID-associated upper gastrointestinal (GI) complications such as bleeding is approximately 1%-1.5%; and reductions in these complications have been demonstrated with misoprostol, proton pump inhibitors (PPIs) (only documented in high-risk patients), and COX-2 selective inhibitors. Clinically significant bleeding from SRMD is relatively uncommon with modern intensive care. Pharmacologic therapy with antisecretory drugs may be used in high-risk patients (eg, mechanical ventilation >or=48 hours), although the absolute risk reduction is small, and a decrease in mortality is not documented.
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Affiliation(s)
- Loren Laine
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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Abstract
H2-receptor antagonist drug therapy is the mainstay of peptic ulcer treatment in the USA. About 75% of patients in intensive care units receive parenteral H2-antagonists. The rationale for their use is that parenteral H2-antagonists offer about a four-fold protective effect compared with placebo against significant upper gastrointestinal haemorrhage. Parenteral administration of H2-receptor antagonists appears to be preferred to oral antacid or sucralfate regimens because of ease of administration and, perhaps, lower treatment costs. Recommended dosage schedules for intravenously administered H2-receptor antagonists are at fixed intervals, 6- to 8-h intervals for cimetidine and ranitidine and 12-h intervals for famotidine. These dosage schedules assume a fixed dose-response relationship (i.e. a given dose of H2-antagonist results in equivalent acid suppression throughout the circadian, or 24-h, period). However, human basal gastric acid secretion exhibits circadian variation, with peak rates occurring during the evening hours. Recent evidence from 24-h continuous intragastric pH studies in fasting patients with healed duodenal ulcer suggests that larger doses of intravenous H2-antagonists are required in the evening than in the morning to achieve equivalent acid suppression. These findings are consistent with a changing H2-antagonist dose/acid-inhibiting response over the circadian period. Continuous infusion has the advantage of providing consistent and sustained suppression of gastric acid secretion in patients at risk for stress ulceration. Results of a double-blind, randomized, crossover study indicated that equally effective suppression of acidity and time-to-onset of pharmacological effect can be achieved with and without priming bolus doses of ranitidine, and presumably other H2-receptor antagonists as well.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J G Moore
- Department of Medicine, Salt Lake Veterans Affairs Medical Center, Utah 84148
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Rubulotta F, Gullo A, Iscra F. Recommendations for ulcer prophylaxis in the treatment of patients with severe sepsis and septic shock: a dog chasing its tail? Intensive Care Med 2007; 33:718-20. [PMID: 17323048 DOI: 10.1007/s00134-007-0551-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2006] [Accepted: 01/16/2007] [Indexed: 10/23/2022]
Affiliation(s)
- Francesca Rubulotta
- Department of Anesthesia and Intensive Care, Catania School of Medicine, University of Catania, Via Matteo Ricci 21, 95126, Catania, Sicily, Italy.
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See KC, Phua J, Lee KH. Severe Sepsis and Septic Shock in Adult Patients: An Approach to Management and Future Trends. Int J Artif Organs 2006; 29:197-206. [PMID: 16552667 DOI: 10.1177/039139880602900206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Severe sepsis is sepsis associated with acute organ dysfunction. Septic shock in turn, implies severe sepsis that has led to circulatory shock refractory to fluid resuscitation alone. The immediate approach to severe sepsis follows the ABCs of resuscitation: Airway, Breathing, and Circulation. Special emphasis on the circulation involves early goal-directed therapy, adequate fluid resuscitation, and vasopressor/inotropic support. Once the patient's cardiorespiratory status is stabilized, efforts must be directed at uncovering the source and empirically yet accurately treating the infective underpinnings of severe sepsis. Following that, each of the patient's other organ systems at risk needs to be addressed: Renal/metabolic, gastrointestinal, hematological, and endocrine. Novel treatments will target both the proinflammatory and procoagulation cascades of sepsis.
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Affiliation(s)
- K C See
- Department of Medicine, National University Hospital, Singapore.
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Affiliation(s)
- Mitchell J. Spirt
- Mitchell J. Spirt is an assistant clinical professor of medicine in the Division of Gastroenterology, University of California, Los Angeles School of Medicine, Los Angeles, Calif, and is the chief of gastroenterology at Century City Doctors Hospital in Century City, Calif. Sandra Stanley is a gastrointestinal staff nurse at the Specialty Surgical Center in Beverly Hills, Calif
| | - Sandra Stanley
- Mitchell J. Spirt is an assistant clinical professor of medicine in the Division of Gastroenterology, University of California, Los Angeles School of Medicine, Los Angeles, Calif, and is the chief of gastroenterology at Century City Doctors Hospital in Century City, Calif. Sandra Stanley is a gastrointestinal staff nurse at the Specialty Surgical Center in Beverly Hills, Calif
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Affiliation(s)
- Michael F McGee
- Department of Surgery, Case Western Reserve University School of Medicine, Case Medical Center, Cleveland, OH 44106, USA
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Katsinelos P, Kountouras J, Paroutoglou G, Beltsis A, Mimidis K, Pilpilidis I, Zavos C. Severe acute haemorrhagic gastritis controlled by hydrogen peroxide. Eur J Gastroenterol Hepatol 2006; 18:107-10. [PMID: 16357629 DOI: 10.1097/00042737-200601000-00019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
A 92-year-old woman presented with severe acute haemorrhagic gastritis due to abuse of non-steroidal anti-inflammatory drugs (NSAIDs). She was treated with instillation of 150 ml 3% hydrogen peroxide (H2O2) every 2 h via a nasogastric tube. The copious amount of bright red blood through the nasogastric tube started to decline substantially after the first administration of H2O2 and continued to reveal clear material during the second and third instillation of H2O2. The total amount of H2O2 administered was 600 ml. No rebleeding and only a few flame-shaped intramucosal haemorrhages were observed on the following four consecutive daily endoscopic evaluations. These are promising observations which will have to be confirmed with respect to the safety and efficacy of H2O2 treatment by further controlled studies.
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Affiliation(s)
- Panagiotis Katsinelos
- Department of Endoscopy and Motility Unit, Central Hospital, Thessaloniki, and Aristotle University of Thessaloniki, Greece
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