Article

Stress ulcer prophylaxis versus placebo or no prophylaxis in critically ill patients

Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
Intensive Care Medicine (Impact Factor: 7.21). 10/2013; 40(1). DOI: 10.1007/s00134-013-3125-3
Source: PubMed

ABSTRACT

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).
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.
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.
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.

2 Followers
 · 
33 Reads

  • No preview · Article · Jun 2014 · Cleveland Clinic Journal of Medicine

  • No preview · Article · Sep 2014 · Critical Care Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Intensivists frequently prescribe proton pump inhibitors (PPIs) or histamine-2 receptor blockers (H2RBs) to intensive care unit patients for stress ulcer prophylaxis (SUP). Despite the common use of SUP medicines, there is limited high-level evidence to support the choice between them. Aim: To describe self-reported practice of SUP by Australian and New Zealand intensivists. Method: An online questionnaire of intensivists between 13 January and 3 February 2014. Results: Seventy-two intensivists responded to the survey: 61 (85%) practised in public metropolitan ICUs and 13/48 (27%) practised in paediatric ICUs. Fifty-two (72%) respondents indicated that PPIs were their preferred SUP medicine. Respondents estimated that an average of 84% of ventilated and 53% of non-ventilated patients received SUP medicines during their ICU admission. Seven respondents (9%) were concerned or very concerned about the possible increased risk of upper gastrointestinal bleeding associated with H2RBs versus PPIs. Ten respondents (14%) were concerned or very concerned about the possible greater risk of Clostridium difficile infection, and 15 respondents (21%) were concerned or very concerned about the possible greater risk or ventilator-associated pneumonia with PPIs versus H2RBs. Most respondents (64 [89%]) agreed or strongly agreed that there was insufficient evidence to support the choice of an optimal SUP medicine, and 58 respondents (81%) agreed or strongly agreed to patient enrollment in an RCT comparing PPIs with H2RBs. Conclusion: Most survey respondents felt that current evidence is insufficient to justify the preferential use of PPIs or H2RBs for SUP and would enroll patients in a comparative SUP RCT.
    No preview · Article · Sep 2014 · Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine
Show more