Prophylactic proton pump inhibitors in femoral neck fracture patients – A life - and cost-saving intervention

Abstract

INTRODUCTION Acute gastrointestinal stress ulceration is a common and serious complication of trauma. Prophylactic proton pump inhibitors (PPIs) or histamine receptor antagonists have been used in poly-trauma, burns and head and spinal injuries, as well as on intensive care units, for the prevention of acute gastric stress ulcers. METHODS We prospectively studied the use of prophylactic PPIs in with femoral neck fracture patients, gathering data on all acute gastric ulcer complications, including coffee-ground vomiting, malena and haematemesis. We then implemented a treatment protocol in which all patients were given prophylactic PPIs, again prospectively collecting all data. RESULTS Five hundred and fifteen patients were included. Prior to prophylactic PPI, 15% of patients developed gastric stress ulcer complications, with 3% requiring acute intervention with oesophagogastroduodenoscopy (OGD), 5% requiring transfusions and 4% experiencing surgical delays. All patients had delayed discharges. Following PPI implementation, no patients developed gastric stress ulcer complications. CONCLUSIONS Femoral neck fracture patients create a substantial workload for orthopaedic units. The increasingly elderly population often have comorbidities, and concomitantly use medications with gastrointestinal side effects. This, combined with the stress of a fracture and preoperative starvation periods increases the risk of gastric ulcers. Here, the use of prophylactic PPIs statistically reduced the incidence of gastric stress ulcers in patients with femoral neck fractures, resulting in fewer surgical delays, reduced length of hospital stay and reduced stress ulcer-related mortality.

Upper gastrointestinal bleeding in neck of femur fracture patients: a single tertiary centre experience

“…Only 0.65% of patients in our study developed perioperative acute UGIB, which is lower than the reported rate in similar populations …”

“…Only 0.65% of patients in our study developed perioperative acute UGIB, which is lower than the reported rate in similar populations. [4][5][6] Of the previously reported risk factors for UGIB, a history of PUD was found to be a strong risk factor in our study. We did not find associations between UGIB and active smoking, or blood group O.…”

“…Prophylactic PPI has been shown to be protective against stress ulceration and UGIB in the perioperative setting . Fisher et al reported 7% patients on a PPI prior to hospitalisation, and significant UGIB rate reduction with introduction of prophylactic PPI in one third of their patients deemed at risk.…”

“…2,3 One of these important complications is acute upper gastrointestinal ulceration and its related complications. It results in surgical delay, increased length of stay (LOS), 4,5 and represents a significant risk factor for mortality at 30 days and 1 year. 4,[6][7][8] The reported incidence of perioperative acute upper gastrointestinal bleeding (UGIB) varies widely in the literature, ranging from1 to 15%.…”

“…4,[6][7][8] The reported incidence of perioperative acute upper gastrointestinal bleeding (UGIB) varies widely in the literature, ranging from1 to 15%. [4][5][6][7][8] Risk factors contributing to perioperative UGIB include pre-existing peptic ulcer disease (PUD), being a current smoker, post-operative use of an antiplatelet agent or non-steroidal anti-inflammatory drugs, and blood group O. 4 The Prince Charles Hospital is a tertiary referral centre with a large dedicated orthogeriatric unit.…”