Critically ill patients are at increased risk of bleeding from stress-induced gastroduodenal ulceration. Decades ago, ICUs began using pharmacologic prophylaxis on most patients to prevent gastrointestinal bleeding, which had a mortality rate as high as 80%. Before the advent of prophylaxis, the incidence of upper gastrointestinal bleeding was 6% to 25%. Since then, improvements in ICU management have decreased this incidence to 0% to 2.8%. Recent studies suggest that only ICU patients with certain risk factors benefit from ulcer prophylaxis (TABLE). Our search retrieved 20 randomized controlled trials and 6 systematic reviews with meta-analyses from the Medline database since 1990. It was difficult to find a consensus on the matter of stress ulcer prophylaxis because of inconsistencies in the outcomes measured in these studies. We focused on studies examining clinically important bleeding, but even in these studies definitions and measurements vary. Few studies addressed mortality or length of stay; those that did reported no significant difference in either outcome with prophylaxis. Medications used to prevent gastrointestinal bleeding have included antacids, sucralfate, H2RAs, and PPIs. Sucralfate and H2RAs have been studied most frequently, and both agents significantly reduce the incidence of clinically important bleeding in high-risk patients. Compared with placebo, the odds ratio for clinically important bleeding was 0.44 with ranitidine (95% confidence interval [CI], 0.22-0.88) and 0.58 with sucralfate (95% CI, 0.34-0.99). In a population with a clinically important bleeding incidence of 3% to 6%, a range consistent with the most recent studies we reviewed, the number needed to treat to prevent 1 bleeding episode is 30 to 60 for ranitidine and 40 to 79 for sucralfate. Some studies suggest that pharmacologic prophylaxis may increase the incidence of aspiration pneumonia in ventilator-dependent patients. The largest randomized trial addressing this issue (N= 1200) found no significant difference between H2RAs and sucralfate in ventilator-associated pneumonia. Improved ICU management, such as frequent suctioning, upright positioning, and use of enteral nutrition may help prevent nosocomial pneumonia due to aspiration.
|Original language||English (US)|
|Number of pages||2|
|Journal||Journal of Family Practice|
|State||Published - Jan 1 2007|
ASJC Scopus subject areas
- Family Practice