GI Prophylaxis

ICU Seminar 22nd June 2007 UHD By Adrian Donnelly

Introduction
    

1832 Cushing reported ulcer disease associated with surgery and trauma 1842 Curling described a series of severe duodenal ulceration associated with burns Strong association with severe illness and incidence of GI bleeds have been established Major bleeds have a high mortality rate Prophylaxis now a central ICU issue

What is Stress Ulceration?



  

Gastrointestinal mucosal injury related to critical illness Incidence related to severity illness [1] Not related to H.pylori or existing peptic ulcer Multifactorial
 

Hypoperfusion Loss of host defences

Why is it important
   

Mortality with bleeding extremely high 48.5% [2] 87.5% [3] This poor outcome probably a reflection of patients severity of illness rather than bleed itself

What causes it?

What causes it?

  

Damaged mucosa Reduced mucosal blood flow Leads to:

Reduced prostaglandins Mucosal Atrophy Increased permeability Loss of ability to neutralise H+ ions Loss of reparative ability

Risk factors
        

2 studies by Cooke`s group [2,4] Respiratory failure Coagulopathy Sepsis Liver failure Hypotension Renal Failure Duration of Stay Multiple of above risk factors(burns)

Incidence
   

Incidence and Prevalence reducing 1970`s and 1980`s 15% [5] Cooke et al- 1.5% clinically significant [2] Incidence associated with
   

Severity of illness Patient factors Duration ventilation Duration of ICU stay

Treatment
     

Antacid Sucrulfate H2RA PPI Enteral nutrition General Measures

Cook et al JAMA 1996

Type of medical Relative risk of therapy o compared with Placebo or Control Antacids

Relative risk of important bleeding

Relative risk of death

0.66 (0.37-1.17) 0.35(0.09-1.41)

1.42(0.82-2.47)

Sucrulfate

0.58(0.34-0.99)

1.26(0.1212.87) 0.44(0.22-0.88)

1.06(0.67-1.67)

H2 antagonists

0.58(0.42-0.79)

1.15(0.86-1.53)

Cook DJ et al New Eng j 1998

Relative risk of o Relative risk of important bleeding Relative risk of death

H2 antagonist vs sucralfate

0.44(0.21-0.92)

1.18(0.92-1.51)

1.03(0.84-1.26)

Treatment


Evidence suggests that bleeding, but not mortality can be reduced, by all agents. [7] Evidence suggests that H2 receptor antagonists are most efficient in reducing overt and clinically important bleeding in ICU patients. [4] Enteral nutrition and ranitidine protect against bleeding, and an additive effect is seen. [8]

PPI


  

Effectively suppresses gastric pH levels in the ICU patient PPI`s superior to H2RAs for PUD and GRD Data extrapolated in SRMB Omeprazole found to be superior than ranitidine in preventing SRMB[9]

Groups not equal regarding risk

PPI


 

Several studies concluded agents were safe and as effective as an alternative to H2RA Small studies Need for further clinical trials

Enteral Nutrition


Cook et al protective effect of enteral feeding for prevention SRMB (relative risk 0.30)[8] Inconclusive results for enteral feeding being used as SUP[9] Cannot be recommended as sole agent[10]

Treatment Strategy


No current evidence that patients without 1 of 6 major risk factors warrant prophylaxis
     

Shock Sepsis Resp failure Hepatic failure Renal failure Coagulopathy

Treatment Complications
 

  

Nosocomial pneumonia Anti-acid therapy promotes colonisation of gut mucosa Aspiration may cause pneumonia [6][11] Sucralfate doesnt alter gastric pH Pnuemonia rates with ranitidine and sucralfate not statistically different[12]

Treatment Complications


Nosocomial pneumonia H2RA vs PPI

 

14% patients on ranitidine developed NP 3% patients on omeprazole developed NP [13]

Discussion and Questions

References


[1] - Pruitt BA, Jr., Foley FD, Moncrief JA. Curling's ulcer: a clinical-pathology study of 323 cases. Ann Surg 1970; 172(4):523-539. [2] Cook DJ, Fuller HD, Guyatt GH, Marshall JC, Leasa D, Hall R et al. Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J Med 1994; 330(6):377-381.

References


[3] Skillman JJ, Bushnell LS, Goldman H, Silen W. Respiratory failure, hypotension, sepsis, and jaundice. A clinical syndrome associated with lethal hemorrhage from acute stress ulceration of the stomach. Am J Surg 1969; 117(4):523-530. [4] Cook D, Guyatt G, Marshall J, Leasa D, Fuller H, Hall R et al. A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group. N Engl J Med 1998; 338(12):791-797.

References


[5] Shuman RB, Schuster DP, Zuckerman GR. Prophylactic therapy for stress ulcer bleeding: a reappraisal. Ann Intern Med 1987; 106(4):562-567. [6] Cook DJ, Walter SD, Cook RJ, Griffith LE, Guyatt GH, Leasa D et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med 1998; 129(6):433-440.

References
   

[7] Cook DJ et al JAMA 1996 [8] Cook DJ et al. Crit Care Med 1999; 27:2812 [9] Raff et al Burns 1997; 23:313-318 [10] MacClaren et al: Use of enteral nutrition for stress ulcer prophylaxis. Ann Pharmacother 2001;35:16141623 [11] Tryba :role of acid suppressants in intensive care medicine. Best Pract Res Clin Gastroenterol

References


[12] Tryba M: Sucalfate vs antacids or H2RA for SUP: A meta-analysis on efficacy and pneumonia rate. Crit Care Med 1990;16:44-49 [13] Levy et al :Comparison of omeprazole and ranitidine for SUP Dig Dis Sci 1997 42:12551259