Stress Ulcer Prophylaxis in Critically Ill Children: A Multicenter Observational Study

Abstract

Objective: To describe current stress ulcer prophylaxis practice in Canadian PICUs. Design: Multicenter cohort study. We defined stress ulcer prophylaxis as the use of a proton-pump inhibitor, histamine-2 receptor antagonist, or sucralfate within the first 2 PICU days among children who had not been on these medications at home and had no evidence of gastrointestinal bleeding. Setting: Seven PICUs in Canada. Patients: Three hundred seventy-eight children requiring mechanical ventilation. Interventions: None. Measurements and Main Results: Children were ventilated for a median (interquartile range) of 2 days (1–6 d) and stayed in the PICU for a median (interquartile range) of 4 days (2–10 d). The median (interquartile range) age was 1.3 years (0.3–6.7 yr). Seventy percent of all children received acid suppression during their PICU stay. One hundred sixty-seven (54%) of the 309 children eligible for stress ulcer prophylaxis received it. Histamine-2 receptor antagonists were the most frequently used class (66%), followed by proton-pump inhibitors (47%) and sucralfate (4%), and 20% received more than one class. Stress ulcer prophylaxis was continued on the PICU transfer orders for 34% of these children. Children who received prophylaxis were older and had a higher Pediatric Risk of Mortality III score, more often received nonsteroidal anti-inflammatory drugs and systemic corticosteroids and received less enteral nutrition. In multivariate analysis, age and invasive mechanical ventilation were independently associated with an increased likelihood of receiving stress ulcer prophylaxis and receiving feeds was independently associated with a decreased likelihood of receiving stress ulcer prophylaxis. Gastrointestinal bleeding was reported in 21 (6%) of 378 children; three (0.8%) were clinically important. Eighteen percent were treated for a new respiratory tract infection, and 1% developed Clostridium difficile–associated diarrhea. Conclusions: Stress ulcer prophylaxis is common in Canadian PICUs. Clinically important gastrointestinal bleeding and C. difficile–associated diarrhea are rare, and the utility of routine prophylaxis should be examined.

Prophylactic acid suppressants in children in the intensive care unit: a systematic review with meta‐analysis and trial sequential analysis

“…This rate is significantly higher than rates reported in observational studies. A recent study assessed current practice and bleeding rates in Canadian PICUs and observed that GI bleeding occurred in 6% of the children and clinically important GI bleeding in 0.8% 46 . This discrepancy could potentially reflect improvements in intensive care in recent decades (>50% of trials included are more than 20 years old), the large heterogeneity in trial quality, trial populations and definitions of GI bleeding in the included trials of this systematic review.…”

eSIMPLER: A Dynamic, Electronic Health Record–Integrated Checklist for Clinical Decision Support During PICU Daily Rounds

“…We speculate that eSIMPLER’s clear display of CDS for indications, current EHR orders (or lack thereof), and a prompt to indicate whether the team believed SUP was indicated each day led to a “pause” and team discussion whether to initiate, continue, or discontinue SUP and ultimately reduced discrepancies between SUP indications, team intent, and SUP prescribing. Although we did not specifically evaluate whether SUP use was clinically indicated, prior studies have shown high rates of SUP use in the PICU, but low incidence of clinically significant gastrointestinal bleeding (19, 20). We also showed that VTE prophylaxis prescribing increased in proportion to increased need for VTE prophylaxis recorded in eSIMPLER.…”

Challenges and advances in nutrition for the critically ill child

“…Medications, including histamine-2-receptor antagonists (H2RA) and proton pump inhibitors (PPIs), are often used to protect the gastrointestinal tract from mucosal damage during critical illness [57 ▪▪ ] and reduce the risk of gastrointestinal bleeding that may occur due to stress-related ulceration [58]. A large multicenter observational study in Canadian PICUs and a separate international, observational study both reported that ∼70% of patients received stress ulcer prophylaxis (SUP) [1 ▪▪ ,57 ▪▪ ]. In the Canadian study, the distribution of SUP use was 66% for H2RA and 47% for PPIs and patients who received SUP were older, received less enteral nutrition and received more corticosteroids or nonsteroidal anti-inflammatory drugs [57 ▪▪ ].…”