Prophylaxis of Upper Gastrointestinal Tract Bleeding in Mechanically Ventilated Patients

Cannon, Louis; Heiselman, Darell; Gardner, William G.; Jones, Jeffrey A.

doi:10.1001/archinte.1987.00370120037009

Cited by 52 publications

(3 citation statements)

References 18 publications

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“…Network meta-analysis estimates from 51 trials including 10 277 patients11121439404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687 demonstrated odds ratios for all comparisons close to 1.0 with moderate or very low certainty (table 1 of appendix 8). PPIs probably have no impact on mortality compared with placebo or no prophylaxis (odds ratio 1.06 (95% credible interval 0.90 to 1.28), 13 more per 1000 patients, moderate certainty, table 1 of appendix 8), and neither do H2RAs (0.96 (0.79 to 1.19), 9 fewer per 1000 patients, moderate certainty, table 1 of appendix 8).…”

Section: Resultsmentioning

confidence: 99%

“…Overt gastrointestinal bleeding is bleeding without the consequences of clinically important gastrointestinal bleeding such as haemodynamic changes, transfusion, haemoglobin decrease, or need for surgery. Sixty five trials including 11 662 patients11121314394142434445464748495052535455565758606162636465666768697172737475767778798081828385868789909192939495969899100101102103104105106107 reported on overt bleeding. Subgroup analysis showed that concealment or blinding (the combined variable) influenced results for the comparisons of PPIs versus placebo and H2RAs versus sucralfate, and missing outcome data influenced results for PPIs versus placebo (table 4 and appendix 10).…”

Section: Resultsmentioning

confidence: 99%

“…Twenty three trials including 3625 patients111239404143465354565961646571737879818285919596 reported duration of mechanical ventilation or duration of intubation. Results suggested no important difference between any of interventions in terms of duration of mechanical ventilation or duration of intubation (table 6 of appendix 8).…”

Section: Resultsmentioning

confidence: 99%

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Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: systematic review and network meta-analysis

Wang

et al. 2020

BMJ

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ObjectiveTo determine, in critically ill patients, the relative impact of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), sucralfate, or no gastrointestinal bleeding prophylaxis (or stress ulcer prophylaxis) on outcomes important to patients.DesignSystematic review and network meta-analysis.Data sourcesMedline, PubMed, Embase, Cochrane Central Register of Controlled Trials, trial registers, and grey literature up to March 2019.Eligibility criteria for selecting studies and methodsWe included randomised controlled trials that compared gastrointestinal bleeding prophylaxis with PPIs, H2RAs, or sucralfate versus one another or placebo or no prophylaxis in adult critically ill patients. Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias. A parallel guideline committee (BMJ Rapid Recommendation) provided critical oversight of the systematic review, including identifying outcomes important to patients. We performed random-effects pairwise and network meta-analyses and used GRADE to assess certainty of evidence for each outcome. When results differed between low risk and high risk of bias studies, we used the former as best estimates.ResultsSeventy two trials including 12 660 patients proved eligible. For patients at highest risk (>8%) or high risk (4-8%) of bleeding, both PPIs and H2RAs probably reduce clinically important gastrointestinal bleeding compared with placebo or no prophylaxis (odds ratio for PPIs 0.61 (95% confidence interval 0.42 to 0.89), 3.3% fewer for highest risk and 2.3% fewer for high risk patients, moderate certainty; odds ratio for H2RAs 0.46 (0.27 to 0.79), 4.6% fewer for highest risk and 3.1% fewer for high risk patients, moderate certainty). Both may increase the risk of pneumonia compared with no prophylaxis (odds ratio for PPIs 1.39 (0.98 to 2.10), 5.0% more, low certainty; odds ratio for H2RAs 1.26 (0.89 to 1.85), 3.4% more, low certainty). It is likely that neither affect mortality (PPIs 1.06 (0.90 to 1.28), 1.3% more, moderate certainty; H2RAs 0.96 (0.79 to 1.19), 0.9% fewer, moderate certainty). Otherwise, results provided no support for any affect on mortality, Clostridium difficile infection, length of intensive care stay, length of hospital stay, or duration of mechanical ventilation (varying certainty of evidence).ConclusionsFor higher risk critically ill patients, PPIs and H2RAs likely result in important reductions in gastrointestinal bleeding compared with no prophylaxis; for patients at low risk, the reduction in bleeding may be unimportant. Both PPIs and H2RAs may result in important increases in pneumonia. Variable quality evidence suggested no important effects of interventions on mortality or other in-hospital morbidity outcomes.Systematic review registrationPROSPERO CRD42019126656.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: systematic review and network meta-analysis

Wang

et al. 2020

BMJ

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Effects of Sucralfate vs Antacids on Gastric Pathogens

Ephgrave¹,

Kleiman-Wexler²,

Pfaller³

et al. 1998

Arch Surg

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Background: Unblinded studies suggested that sucralfate prophylaxis for stress ulcers is associated with a lower rate of nosocomial pneumonia than acid-reducing approaches. We performed a randomized, double-blind, double-sham clinical trial comparing the exact microbial effects of each treatment. RESULTS PRESTUDY COMPARISONS OF THE PATIENT GROUPS The patients who were randomly assigned to receive antacid or sucralfate stress ulcer prophylaxis were similar in most risk factors for postoperative complications

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