VARICEAL BLEEDING
Hayes, PC., et al (1990) “Meta-analysis of value of propanolol in prevention of variceal haemorrhage” Lancet 336:153-156
- meta-analysis of controlled trials
- looking at prevention of primary and secondary variceal bleeding
- propanolol works for primary prevention
- endoscopic band ligation for acute bleeding
ULCER PREVENTION AND TREATMENT
Lay, JY., et al (2000) “Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers” N Eng J Med 343:310-316
- double blind RCT
- n = 240
- actively bleeding ulcers or non-bleeding visible vessels after treatment with adrenaline + thermocoagulation
- omeprazole 80mg bolus -> 8mg/hr for 72 hours VS placebo
- all patients received 20mg PO omeprazole for 8/52
- significant reduction in rate of bleeding within 30 days (most of which happened in first 3 days) in treatment group
- no difference in mortality
- no difference in number of patient requiring surgery
Messori, A., et al (2000) “Bleeding and pneumonia in intensive care patients given ranitidine and sucralfate for prevention of stress ulcer: meta-analysis of randomised controlled trials” BMJ 321:1103-1106
- incidence of pneumonia and bleeding -> thought to be potential adverse effect of gastric acid suppression c/o bacterial overgrowth
- small numbers in studies
- no benefit from ranitidine vs placebo
- no benefit from sucralfate vs placebo
- increase risk of nosocomial pneumonia in ranitidine vs sucralfate
-> muscosal ischaemia more important than acidity in stress ulcer formation
-> despite this evidence use of PPI is widespread in critical care
Parsonnet, J. et al (2005) “Clinician-discoverers – Marshal, Warren and H. pylori” N Engl J Med, 353:2421-2423
- acknowledgement of these guys discovery
- H.pylori causes: chronic superficial gastritis, chronic active gastritis, peptic ulcer disease and gastric adenocarcinoma
Cook, D et al (1998) “A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation” Canadian Critical Care Trials Group, NEJM, 338:791-7
- MRCT
- placebo vs ranitidine vs sucralfate
-> GIH: placebo ( ), ranitidine (1.7%), sucralfate (3.8%) – P < 0.05
-> pneumonia incidence: ranitidine (19.2%), sucralfate (16.2%) – P > 0.05
-> no change in LOS or mortality
Mariki, P. E. et al (2010) “Stress ulcer prophylaxis in the new millennium: A systematic review and meta-analysis” Critical Care Medicine: Volume 38 – Issue 11 – pp 2222-2228
Background
- – stress ulceration uncommon (1%)
– prophylaxis may be unwarranted if feeding can be established early
– prophylaxis may increase risk of hospital-acquired pneumonia and Clostrodium difficile infection - – meta-analysis of RCT’s
– histamine-2 receptor blockers vs placebo
– 17 studies (1836 patients) - – primary end point: clinically significant GIH
– secondary end points: incidence of HAP and hospital mortality.
– sub group analysis performed by grouping studies by enteral nutrition or no enteral nutrition - -> significant decrease in risk of gastrointestinal bleeding (OR 0.47, p < 0.02) -> BUT only noted in a subgroup of patients who did not receive enteral nutrition (OR 1.26, CI 0.43-3.7)
-> if patients fed, prophylaxis did not alter the risk of GI bleeding
-> no increase in risk of HAP overall
-> BUT, those who were fed had an increased risk of HAP (p 0.02, or 2.81)
-> stress ulcer prophylaxis did not change mortality
-> the subgroup who received stress ulcer prophylaxis AND enteral feeding had a elevated HAP rate (? both increasing gastric pH and thus allowing gastric multiplication of bacteria and subsequent aspiration)
Internal Validity
- clinically significant GIH was defined by each individual study
- if there wasn’t a definition of clinically significant bleeding then endoscopic bleeding was used.
- used H2 antagonists: cimetidine, ranitidine, famotidine
- varying doses
- some studies ran infusions
- only 3 studies looked at enteral nutrition
External Applicability
- we use omeprazole
- those who were fed may have been sicker than those that weren’t which may explain increase in HAP and death (confounding)
AN APPROACH
- feed early unless contraindicated
- don’t use prophylaxis if feeding established
- if unable to establish enteral feed, risk assess for GIH: if high risk -> use prophylaxis
- if develops stress ulcers treat
- vigilance for the development of hospital acquired pneumonia
- may need to take ulcer prophylaxis of FASTHUG sticker!
Critical Care
Compendium
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