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 A.; Leasa, David; Fuller, Hugh D.; Hall, Richard; Peters, Sharon; Rutledge, Frank; Griffith, Lauren; Mclellan, Allan; Wood, Gordon; Kirby, Ann; Tweeddale, Martin; Pagliarello, Joe; Johnston, Richard

doi:10.1056/nejm199803193381203

Cited by 656 publications

(320 citation statements)

References 40 publications

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“…However, in a recent multicentre, randomised study of 1200 patients, no significant difference in VAP rates, ICU stay or mortality could be demonstrated, although there was a trend towards lower VAP rates with sucralfate. The ranitidine group had lower rates of clinically significant gastrointestinal bleeding than the sucralfate group (1.7% vs. 3.8%) [79]. These conflicting data make recommendations difficult.…”

Section: Gastric Alkalinisationmentioning

confidence: 99%

Ventilator‐associated pneumoniaDiagnosis, pathogenesis and prevention

Young¹,

Ridley²

1999

Anaesthesia

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SummaryVentilator-associated pneumonia is common, difficult to diagnose, affects the most vulnerable of patients and carries a high mortality. During prolonged mechanical ventilation the oropharynx, sinuses, dentition and stomach of critically ill patients become colonised with pathogenic bacteria. Colonised secretions pool in the oropharynx and subglottic space. These secretions repeatedly gain access to the lower airways by leakage past the tracheal tube cuff. If host defence mechanisms are overwhelmed, multiplication occurs in the lower respiratory tract producing an inflammatory response in the bronchioles and alveoli. The inflammatory response is characterised by capillary congestion, leucocyte and macrophage infiltration and fibrinous exudation into the alveolar spaces. If this inflammatory response occurs more than 48 h after intubation, it is called ventilatorassociated pneumonia. Prevention depends on reducing upper airway and gastrointestinal reservoirs of bacteria, reducing or abolishing aspiration of these bacteria past the tracheal tube cuff and enhancing bacterial clearance from the lower airways. Despite an increased understanding of the pathogenesis and diagnosis of ventilator-associated pneumonia (VAP), prevention has remained problematic. There is now good evidence for continuous leakage of infected secretions past the tracheal tube cuff being responsible for VAP. As a result, VAP strikes critically ill patients and increases their morbidity and mortality. The aim of this review is to discuss the diagnosis and pathogenesis of VAP, including a brief review of natural defence mechanisms. The review also covers the prevention of VAP with special reference to new developments aimed at reducing aspiration past the cuff. Definition

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Section: Gastric Alkalinisationmentioning

confidence: 99%

Ventilator‐associated pneumoniaDiagnosis, pathogenesis and prevention

Young¹,

Ridley²

1999

Anaesthesia

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“…In intensive care units (ICU), predisposing conditions for stress-related mucosal disease are prolonged mechanical ventilation, coagulopathy, shock, major trauma, surgery, or burn, and multiple organ failure [3,4]. However, randomized trials have suggested that only the first two entities might be relevant, as in their absence the incidence of clinical significant bleeding is less than 0.1% [4,5].…”

Section: Introductionmentioning

confidence: 99%

Stress-related mucosal disease: Incidence of bleeding and the role of omeprazole in its prophylaxis

Amaral

Favas

Alves

et al. 2010

European Journal of Internal Medicine

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Background: Upper gastrointestinal bleeding is the severe complication of stress-related mucosal disease in hospitalized patients. In intensive care units (ICU), risk factors are well defined and only mechanical ventilation and coagulopathy proved to be relevant for significant bleeding. On the contrary, in non-ICU settings there is no consensus about this issue. Nevertheless, omeprazole is still widely used in prophylaxis of bleeding. The objective of our study was to evaluate the relevance of stress-related mucosal disease bleeding in patients admitted to an internal medicine ward, and the role of omeprazole in its prophylaxis. Methods: We conducted a retrospective study in which we analysed consecutive patients who were admitted to our ward over a year. We recorded demographic characteristics of the patients, potential risk factors for stress-related mucosal disease (clinical data, laboratory, and medication), administration of prophylactic omeprazole, and total cost of this prophylaxis. Patients with active gastrointestinal bleeding on the admission were excluded. We recorded every upper gastrointestinal bleeding event with clinical relevance. Results: Five hundred and thirty-five patients, mean age 70 years, mean length of stay 9.6 ± 7.7 days; 140 (26.2%) patients were treated with 40 mg of omeprazole intravenously, 193 (36.1%) with 20 mg of omeprazole orally, and 202 (37.8%) patients had no prophylaxis. There was only one episode (0.2%) of clinically relevant bleeding. Conclusion: In patients admitted to an internal medicine ward, incidence of upper gastrointestinal bleeding as a complication of stress-related mucosal disease is low. We found that there is no advantage in prophylaxis with omeprazole.

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confidence: 99%

“…Clinicians worry about bleeding because historical studies have reported a strong association with mortality [5,6]. However, even when acid-suppressive drugs have shown a reduction in episodes of clinically significant bleeding, this has not translated into a reduction in mortality [5,6]. These results suggest that bleeding simply identifies patients at greater risk of dying and, when treated, bleeding per se does not cause death [3].…”

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confidence: 99%