PO-0138 Stress Induced Gastrointestinal Bleeding In A Paediatric Intensive Care Unit : Which Risk Factors Should Necessitate Prophilaxis ?

Şahin, Şanlıay; Yazıcı, Mutlu Uysal; Ayar, Ganime; Köksal, Tülin; Akman, Alkım Öden; Gündüz, Ramiz Coşkun; Kirsacoglu, C Tuna; Gülerman, Hacer Fulya

doi:10.1136/archdischild-2014-307384.801

Cited by 4 publications

(6 citation statements)

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“…Critically ill children are at risk of upper gastrointestinal (GI) bleeding. In observational studies the incidence of important bleeding ranged from 0.4 to 5% [ 1 – 5 ]. This bleeding is associated with more red blood cell transfusions, longer duration of mechanical ventilation and stay in the pediatric intensive care unit (PICU) as well as increased healthcare costs [ 6 ].…”

Section: Introductionmentioning

confidence: 99%

Pediatric intensive care stress ulcer prevention (PIC-UP): a protocol for a pilot randomized trial

Duffett

Choong

Foster

et al. 2017

Pilot Feasibility Stud

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BackgroundDespite sparse pediatric data on effectiveness, the majority of critically ill children receive medications to prevent gastrointestinal (GI) bleeding. Stress ulcer prophylaxis may have unintended consequences—increasing the risk of nosocomial infections—which may be more serious and common than the bleeding which these drugs are prescribed to prevent. Randomized controlled trials (RCTs) in pediatric critical care are exceptionally challenging to complete, thus a rigorous pilot RCT is crucial. The objective of this pilot RCT is to assess the feasibility of a large multicentre RCT of stress ulcer prophylaxis with pantoprazole to prevent upper GI bleeding vs. placebo.MethodsA multi-centre blinded pilot RCT of 120 children in six Canadian PICUs. Children expected to require mechanical ventilation for more than 48 h will be randomized to receive intravenous pantoprazole 1 mg/kg or identical placebo once daily until they no longer need mechanical ventilation. We have four feasibility outcomes and will consider the trial successful if we achieve:Effective screening: If >80% of eligible patients are approached for consent.Timely enrollment: if >80% of participants receive their first dose of the assigned study drug within 1 day of becoming eligible.Participant accrual: If the average monthly enrolment is two or more participants per centre per month.Protocol adherence: if >90% of doses are administered according to the protocol. DiscussionThere are many uncertainties about the risks and benefits of stress ulcer prophylaxis. In an era of widespread use—where clinicians prescribe prophylaxis to the more severely ill—a large, rigorous RCT is required. A trial to determine if a strategy of withholding stress ulcer prophylaxis is not inferior to a strategy of routine stress ulcer prophylaxis will be challenging. A carefully designed and implemented pilot trial is essential.Trial registrationClinicalTrials.gov:NCT02929563 (Registered October 3, 2016).

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Section: Introductionmentioning

confidence: 99%

Pediatric intensive care stress ulcer prevention (PIC-UP): a protocol for a pilot randomized trial

Duffett

Choong

Foster

et al. 2017

Pilot Feasibility Stud

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“…Patients were divided into 2 groups based on a pH value ≥4 at any time (Table 2). Patients with a pH value ≥4 did not have a difference in IVR dose per kilogram (0.88 ± 0.31 vs. 0.88 ± 0.26 mg/kg per dose, p = 0.86) or frequency of dosing (7.9 ± 3.2 vs. 7.9 ± 3.2 hours, p = 0.89), but had more nasogastric samples obtained (1 [1,2] vs. 2 [1,3], p < 0.001), had more doses given prior to the pH sample (4 [2,8] vs. 5 [2,10], p = 0.04), and had gastric pH samples taken earlier after a dose of IVR (5.9 ± 4.7 vs. 6.7 ± 5.0 hours, p < 0.001; Table 2).…”

Section: Resultsmentioning

confidence: 99%

“…The ability of IVR to maintain a gastric pH ≥4, the goal for prevention of stress-induced bleeding, has been shown to be variable, likely due to myriad potential patient factors that can affect gastric acid production and IVR efficacy. [8][9][10][11] We performed a large retrospective review of IVR in the critically ill pediatric patient in order to ascertain patient and dosing regimens associated with a goal gastric pH value ≥4.…”

Section: Introductionmentioning

confidence: 99%

Evaluation of Intravenous Ranitidine on Gastric pH in Critically Ill Pediatric Patients

Moffett¹,

Schmees²,

Gutierrez³

et al. 2019

The Journal of Pediatric Pharmacology and Therapeutics

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OBJECTIVE To determine the dosing regimen of intravenous ranitidine (IVR) most likely to achieve a gastric pH of ≥4 in critically ill pediatric patients.METHODS A retrospective cohort study was designed and included patients younger than 19 years with gastric pH samples taken from a nasogastric tube within 24 hours after a dose of IVR in an intensive care unit. Data collection included patient demographics, clinical variables, IVR dosing, and gastric pH samples. Descriptive statistical analysis and multivariable logistic regression analysis with clustering of patients was performed to determine variables associated with odds of obtaining a pH of ≥4.RESULTS A total of 628 patients (1356 nasogastric samples) met study criteria (median age 1.3 years [IQR, 0.33, 5.7 years]; 53% male). The IVR dose was 0.90 ± 0.30 mg/kg per dose every 8.1 ± 2.9 hours, and 60.9% of patients (n = 383) had a pH ≥4. Patients with a pH value ≥4 had gastric pH samples taken earlier after a dose of IVR (6.7 ± 5.0 vs. 5.9 ± 4.7 hours, p < 0.001) but had no difference in IVR dose per kilogram (0.88 ± 0.31 vs. 0.88 ± 0.26, p = 0.86) or frequency of dosing (7.9 ± 3.2 vs. 7.9 ± 3.2 hours, p = 0.89). A multivariable logistic regression model identified increasing age, decreased kidney function, and decreased time to pH sample after an IVR dose with significantly greater odds of pH ≥4.CONCLUSIONS The IVR dosing to maintain a gastric pH ≥4 in critically ill pediatric patients should occur more frequently than every 8 hours. Gastric pH evaluation may be necessary to assess IVR efficacy.

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“…Approximately 30% of the children who received antacid prophylaxis developed any upper GI bleeding. Mechanical ventilation, trauma, coagulopathy, thrombocytopenia, higher severity score at admission, renal and hepatic failure, hypotension, heart failure, and arrhythmia were found to be associated with the development of any upper GI bleeding ( 27 ).…”

Section: Medical Bleedingmentioning

confidence: 99%

Bleeding in Critically Ill Children—Review of Literature, Knowledge Gaps, and Suggestions for Future Investigation

2021

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Clinically significant bleeding complicates up to 20% of admissions to the intensive care unit in adults and is associated with severe physiologic derangements, requirement for significant interventions and worse outcome. There is a paucity of published data on bleeding in critically ill children. In this manuscript, we will provide an overview of the epidemiology and characteristics of bleeding in critically ill children, address the association between bleeding and clinical outcomes, describe the current definitions of bleeding and their respective limitations, and finally provide an overview of current knowledge gaps and suggested areas for future research.

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PO-0138 Stress Induced Gastrointestinal Bleeding In A Paediatric Intensive Care Unit : Which Risk Factors Should Necessitate Prophilaxis ?

Abstract: of 12 M (3-84 M). Children with bloody diarrhoea acquired tolerance earlier, median age 8 M (5-23 M), than the group with cutaneous symptoms, median age 14 M (4-84 M), p = 0.005.It's safe and beneficial, both for children and parents, to perform OFC from 6 to 12 M.

Cited by 4 publications

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Pediatric intensive care stress ulcer prevention (PIC-UP): a protocol for a pilot randomized trial

Pediatric intensive care stress ulcer prevention (PIC-UP): a protocol for a pilot randomized trial

Evaluation of Intravenous Ranitidine on Gastric pH in Critically Ill Pediatric Patients

Bleeding in Critically Ill Children—Review of Literature, Knowledge Gaps, and Suggestions for Future Investigation

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