A Comparison of Sucralfate and Ranitidine for the Prevention of Upper Gastrointestinal Bleeding in Patients Requiring Mechanical Ventilation

Cook, Deborah J.; Guyatt, Gordon; Marshall, John K.; Leasa, David; Fuller, Hugh D.; Hall, Richard; Peters, Sharon; Rutledge, Frank; Griffith, Lauren; Mclellan, Allan; Wood, Gordon; Kirby, Ann

doi:10.1097/00132586-199902000-00011

Cited by 93 publications

(48 citation statements)

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“…Incidence of pneumonia with ranitidine v sucralfate (meta-analysis E) —Our fifth meta-analysis included eight randomised studies 3 19 – 26 that compared the incidence of pneumonia with ranitidine and sucralfate (five of these trials19 – 23 had already been included in the meta-analysis by Cook et al). The quality score for these trials was 5.6 (2.3).…”

Section: Resultsmentioning

confidence: 99%

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Bleeding and pneumonia in intensive care patients given ranitidine and sucralfate for prevention of stress ulcer: meta-analysis of randomised controlled

Messori

2000

BMJ

223

115

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Objectives To determine the effectiveness of ranitidine and sucralfate in the prevention of stress ulcer in critical patients and to assess if these treatments affect the risk of nosocomial pneumonia. Design Published studies retrieved through Medline and other databases. Five meta-analyses evaluated effectiveness in terms of bleeding rates (A: ranitidine v placebo; B: sucralfate v placebo) and infectious complications in terms of incidence of nosocomial pneumonia (C: ranitidine v placebo; D: sucralfate v placebo; E: ranitidine v sucralfate). Trial quality was determined with an empirical ad hoc procedure. Main outcome measures Rates of clinically important gastrointestinal bleeding and nosocomial pneumonia (compared between the two study arms and expressed with odds ratios specific for individual studies and meta-analytic summary odds ratios). Results Meta-analysis A (five studies) comprised 398 patients; meta-analysis C (three studies) comprised 311 patients; meta-analysis D (two studies) comprised 226 patients: and meta-analysis E (eight studies) comprised 1825 patients. Meta-analysis B was not carried out as the literature search selected only one clinical trial. In meta-analysis A ranitidine was found to have the same effectiveness as placebo (odds ratio of bleeding 0.72, 95% confidence interval 0.30 to 1.70, P = 0.46). In placebo controlled studies (meta-analyses C and D) ranitidine and sucralfate had no influence on the incidence of nosocomial pneumonia. In comparison with sucralfate, ranitidine significantly increased the incidence of nosocomial pneumonia (meta-analysis E: 1.35, 1.07 to 1.70, P = 0.012). The mean quality score in the four analyses (on a 0 to 10 scale) ranged from 5.6 in meta-analysis E to 6.6 in meta-analysis A. Conclusions Ranitidine is ineffective in the prevention of gastrointestinal bleeding in patients in intensive care and might increase the risk of pneumonia. Studies on sucralfate do not provide conclusive results. These findings are based on small numbers of patients, and firm conclusions cannot presently be proposed.

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Section: Resultsmentioning

confidence: 99%

“…Another problem is that the most recent randomised studies on this topic did not include a group with no prophylaxis and compared supposedly active treatments with one another. 3 4…”

Section: Introductionmentioning

confidence: 99%

Bleeding and pneumonia in intensive care patients given ranitidine and sucralfate for prevention of stress ulcer: meta-analysis of randomised controlled

Messori

2000

BMJ

223

115

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“…The latter 2 groups also tend to increase the gastric pH, which has been associated with gastric bacterial overgrowth, tracheobronchial colonization, and development of pneumonia. 97,98 On the other hand, sucralfate offers a less protective effect against bleeding than H 2 receptor antagonists. 97 To further complicate the situation, a recent randomized controlled trial performed by Kantorova et al 99 on 287 critically ill patients to compare proton pump inhibitors (omeprazole) and H 2 receptor antagonists (ranitidine and sucralfate) with placebo for SUP found no statistically significant differences in days on ventilator, ICU length of stay, or mortality among any of the 4 groups.…”

Section: Sddmentioning

confidence: 99%

“…97,98 On the other hand, sucralfate offers a less protective effect against bleeding than H 2 receptor antagonists. 97 To further complicate the situation, a recent randomized controlled trial performed by Kantorova et al 99 on 287 critically ill patients to compare proton pump inhibitors (omeprazole) and H 2 receptor antagonists (ranitidine and sucralfate) with placebo for SUP found no statistically significant differences in days on ventilator, ICU length of stay, or mortality among any of the 4 groups. Therefore, the potential benefit of sucralfate at limiting VAP needs to be weighed carefully against the increased risk of significant gastrointestinal bleeding in each individual before choosing it for SUP.…”

Section: Sddmentioning

confidence: 99%

Ventilator-Associated Pneumonia: A Review

Ashraf¹,

Ostrosky-Zeichner²

2012

Hospital Practice

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Ventilator-associated pneumonia (VAP) is the most common infection seen in intensive care units (ICUs); it accounts for one-fourth of the infections occurring in critically ill patients and is the reason for half of antibiotic prescriptions in mechanically ventilated patients. In addition to being a financial burden on ICUs, it continues to contribute significantly to the morbidity and mortality of ICU patients, with an estimated attributable mortality rate of 8% to 15%. While the pathophysiology of VAP remains relatively unchanged, diagnostic techniques and preventive measures are constantly evolving. The focus of this article is on recent trends in VAP epidemiology, modifiable risk factors, diagnostic techniques, challenges in management, and current data on the prevention of VAP. Important messages that the reader should take away include: 1) There is no gold standard for the diagnosis of VAP; whenever VAP is suspected, if feasible, a quantitative culture should be obtained by invasive or noninvasive methods (whichever is more readily available before initiation of antibiotics); 2) Suspicion based on clinical features should prompt the initiation of a broad spectrum of antibiotics depending on suspected pathogens; 3) Close attention should be paid to de-escalation of antibiotics once microbiological results become available or as the patient starts responding clinically; the ideal duration of treatment should be 8 days instead of the conventional 10 to 14 days, except in situations where Pseudomonas may be suspected or the patient's comorbidities dictate otherwise; and 4) Prevention remains the key to reducing the burden of VAP. We promote the proven preventive measures of using noninvasive ventilation when possible, semirecumbent patient positioning, continuous aspiration of subglottic secretions, and oral chlorhexidine washes along with stress ulcer prophylaxis only after careful assessment of the risks versus benefits.

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“…41,[44][45][46][47][48] Meta-analyses evaluating the risk of pneumonia associated with acid-suppressive medications have reported discordant results. [49][50][51][52][53][54] Consensus guidelines considering the relationship between acid-suppressive medications and pneumonia are unresolved. 41 Two more recent metaanalyses that included studies evaluating PPIs have been published.…”

Section: Acid-suppressive Medications: Antacids Histamine-2 Receptormentioning

confidence: 99%

Strategies for Prevention of Ventilator-Associated Pneumonia: Bundles, Devices, and Medications for Improved Patient Outcomes

et al. 2012

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Ventilator-associated pneumonia is associated with significant patient morbidity, mortality, and increased health care costs. In the current economic climate, it is crucial to implement cost-effective prevention strategies that have proven efficacy. Multiple prevention measures have been proposed by various expert panels. Global strategies have focused on infection control, and reduction of lower airway colonization with bacterial pathogens, intubation, duration of mechanical ventilation, and length of stay in the intensive care unit. Routine use of the Institute for Healthcare Improvement ventilator care bundle is widespread, and has been clearly demonstrated to be an effective method for reducing the incidence of ventilator-associated pneumonia. In this article, we examine specific aspects of the Institute for Healthcare Improvement bundle, better-designed endotracheal tubes, use of antibiotics and probiotics, and treatment of ventilator-associated tracheobronchitis to prevent ventilator-associated pneumonia.

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A Comparison of Sucralfate and Ranitidine for the Prevention of Upper Gastrointestinal Bleeding in Patients Requiring Mechanical Ventilation

Cited by 93 publications

References 0 publications

Bleeding and pneumonia in intensive care patients given ranitidine and sucralfate for prevention of stress ulcer: meta-analysis of randomised controlled

Bleeding and pneumonia in intensive care patients given ranitidine and sucralfate for prevention of stress ulcer: meta-analysis of randomised controlled

Ventilator-Associated Pneumonia: A Review

Strategies for Prevention of Ventilator-Associated Pneumonia: Bundles, Devices, and Medications for Improved Patient Outcomes

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