Stress Ulcer Prophylaxis in Medical ICU Patients: Annual Utilization in Relation to the Incidence of Endoscopically Proven Stress Ulceration

Abstract

Spanish

French

OBJECTIVE:

To measure changes in the proportion of medical intensive care unit (MICU) patients prescribed pharmacologic stress ulcer prophylaxis therapy over a 4-year period in relation to the incidence of stress-related ulceration detected by endoscopy at our institution.

DESIGN:

Retrospective 4-year review of pharmacy and endoscopy databases.

SETTING:

A 35-bed MICU.

PATIENTS:

Patients (n = 2941) admitted to the MICU for longer than 24 hours, between January 1, 1993, and December 31, 1996, without acute gastrointestinal hemorrhage on admission.

METHODS:

Records were reviewed to identify patients prescribed pharmacologic stress ulcer prophylaxis (>24 h of sucralfate or a histamine₂-receptor antagonist [H₂RA]), and patients with evidence of stress ulceration during endoscopy.

RESULTS:

The number of patients per year receiving stress ulcer prophylaxis significantly (p < 0.001) decreased between 1993 and 1996: 1993, 492/693 (71%); 1994, 478/798 (60%); 1995, 295/670 (44%); 1996, 164/780 (21%). There was no difference between years in the median duration of stress ulcer prophylaxis therapy or the proportion of patients receiving sucralfate versus H₂RA therapy. There was no difference (p = 0.91) between years in the annual incidence of definite or possible stress-related ulceration: 1993, 6/693 (0.87%); 1994, 5/798 (0.63%); 1995, 6/670 (0.90%); 1996, 5/780 (0.64%).

CONCLUSIONS:

The incidence of endoscopically proven stress-related ulceration has remained unchanged over the past 4 years in our MICU despite significantly fewer patients receiving pharmacologic stress ulcer prophylaxis therapy.

Keywords

stress ulcer prophylaxis gastrointestinal hemorrhage intensive care unit cimetidine ranitidine sucralfate

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References

McAlhany

Jr Czaja

Pruitt

Jr.

Antacid control of complications from acute gastroduodenal disease after burns. J Trauma 1976;16: 645–9.

Hastings

Skillman

Bushnell

. Antacid titration in the prevention of acute gastrointestinal bleeding. N Engl J Med 1978;298:1041–5.

Pingleton

Hadzima

. Enteral alimentation and gastrointestinal bleeding in mechanically ventilated patients. Crit Care Med 1983;11:13–6.

Wilcox

Spenney

. Stress ulcer prophylaxis in medical patients: Who, what, and how much? Am J Gastroenterol 1988;83:1199–211.

Noseworthy

Cook

. Nosocomial pneumonia, prophylaxis against gastric erosive disease, and clinically important gastrointestinal bleeding: Where do we stand? Crit Care Med 1993;21:1814–6.

Peterson

. Prevention of upper gastrointestinal bleeding. N Engl J Med 1994;330:428–9.

Smythe

Zarowitz

. Changing perspectives of stress gastritis prophylaxis. Ann Pharmacother 1994;28:1073–85.

Navab

Steingrub

. Stress ulcer: Is routine prophylaxis necessary? Am J Gastroenterol 1995;90:708–12.

Eddleston

Vohra

Scott

Tooth

Pearson

McCloy

A comparison of the frequency of stress ulceration and secondary pneumonia in sucralfate- or ranitidine-treated intensive care unit patients. Crit Care Med 1991;19:1491–6.

10.

Ruiz-Santana

Ortiz

Gonzalez

Bolanos

Ruiz-Santana

Manzano

. Stress-induced gastroduodenal lesions and total parenteral nutrition in critically ill patients: Frequency, complications, and the value of prophylactic treatment. A prospective, randomized study. Crit Care Med 1991;19:887–91.

11.

Cook

Pearl

Cook

. The incidence of clinically important bleeding in ventilated patients. J Intensive Care Med 1991;6:167–74.

12.

Ben-Menachen

Fogel

Patel

Touchette

Zarowitz

Hadzijahic

. Prophylaxis for stress-related gastric hemorrhage in the medical intensive care unit. Ann Intern Med 1994;121:568–75.

13.

Cook

Fuller

Guyatt

Marshall

Leasa

Hall

Risk factors for gastrointestinal bleeding in critically ill patients. N Engl J Med 1994;330:377–81.

14.

Brown

Klar

Teres

Leneshow

Sands

. Prospective study of clinical bleeding in intensive care unit patients. Crit Care Med 1988;16: 1171–6.

15.

Zandstra

Stoutenbeek

CHP

. The virtual absence of stress-ulceration related bleeding in ICU patients receiving prolonged mechanical ventilation without any prophylaxis. Intensive Care Med 1994;20:335–40.

16.

Schuster

Rowley

Feinstein

McGue

Zuckerman

. Prospective evaluation of the risk of upper gastrointestinal bleeding after admission to a medical intensive care unit. Am J Med 1984;76:623–30.

17.

Ben-Menachem

McCarthy

Fogel

Schiffman

Patel

Zarowitz

Prophylaxis for stress-related gastrointestinal hemorrhage: A cost-effective analysis. Crit Care Med 1996;24:338–45.

18.

Driks

Craven

Celli

Manning

Burke

Garvin

. Nosocomial pneumonia in intubated patients given sucralfate as compared with antacids or histamine type 2 blockers: The role of gastric colonization. N Engl J Med 1987;317:1376–82.

19.

Ryan

Dawson

Teres

Celoria

Vavab

. Nosocomial pneumonia during stress ulcer prophylaxis with cimetidine and sucralfate. Arch Surg 1993;128:1353–7.

20.

Mustafa

Akturk

Ozen

. Acute stress bleeding prophylaxis with sucralfate versus ranitidine and increase of secondary pneumonia in intensive care unit patients (abstract). Intensive Care Med 1995;21:287.

21.

Knaus

Wagner

Draper

Zimmerman

Bergner

Bastos

. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest 1991;100:1619–36.

22.

Zuckerman

Cort

Shuman

. Stress ulcer syndrome. J Intensive Care Med 1988;3:21–31.

23.

Bland

Altman

. Multiple significance tests: The Bonferroni method. BMJ 1995;310:170.

24.

Bresalier

Gendell

Cello

Meyer

. Sucralfate suspension vs titrated antacid for the prevention of acute stress related gastrointestinal hemorrhage in critically ill patients. Am J Med 1987;83(suppl 3b):110–6.

25.

Pai

Melethil

Cuddy

Hall

. Elevation of serum aluminum in humans on a two-day sucralfate regimen. J Clin Pharmacol 1987;27:213–5.

26.

Robertson

Salusky

Goodman

Norris

Coburn

. Sucralfate intestinal aluminum absorption and aluminum toxicity in a patient on dialysis. Ann Intern Med 1989;111:179–81.

27.

Cantu

Korek

. Central nervous system reactions to histamine₂-receptor blockers. Ann Intern Med 1991;114:1027–34.

28.

Hansten

. Overview of the safety profile of the H₂-receptor antagonists. DICP Ann Pharmacother 1990;24(suppl):S38–41.

29.

Cook

Reeve

Guyatt

Heyland

Griffith

Buckingham

Stress ulcer prophylaxis in critically ill patients. Resolving discordant meta-analyses. JAMA 1996;275:308–14.

30.

Cook

Guyatt

Marshall

Leasa

Fuller

Hall

A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. N Engl J Med 1998;338:791–7.

31.

Ephgrave

Kleiman-Wexler

Adari

. Enteral nutrients prevent stress ulceration and increase intragastric volume. Crit Care Med 1990;18:621–4.

32.

Zarowitz

Petitta

Rudis

Horst

Hyzy

. Bar code documentation of pharmacotherapy services in intensive care units. Pharmacotherapy 1996;16:261–6.

33.

Peura

. Stress-related mucosal damage: An overview. Am J Med 1978;83(suppl 6A):3–6.

34.

Luce

Manning

Siegel

Lipscomb

. In: Gold

Siegel

Russell

Weinstein

, eds. Cost effectiveness in health and medicine. Oxford: Oxford University Press, 1996:128–43.