GI Prophylaxis

1
GI Prophylaxis

• ICU Seminar
• 22nd June 2007
• UHD
• By Adrian Donnelly

2
Introduction

• 1832 Cushing reported ulcer disease associated
  with surgery and trauma
• 1842 Curling described a series of severe
  duodenal ulceration associated with burns
• Strong association with severe illness and
  incidence of GI bleeds have been established
• Major bleeds have a high mortality rate
• Prophylaxis now a central ICU issue

3
What is Stress Ulceration?

• Gastrointestinal mucosal injury related to
  critical illness
• Incidence related to severity illness 1
• Not related to H.pylori or existing peptic ulcer
• Multifactorial
• Hypoperfusion
• Loss of host defences

4
Why is it important

• Mortality with bleeding extremely high
• 48.5 2
• 87.5 3
• This poor outcome probably a reflection of
  patients severity of illness rather than bleed
  itself

5
What causes it?
6
What causes it?

• Damaged mucosa
• Reduced mucosal blood flow
• Leads to
• Reduced prostaglandins
• Mucosal Atrophy
• Increased permeability
• Loss of ability to neutralise H ions
• Loss of reparative ability

7
Risk factors

• 2 studies by Cookes group 2,4
• Respiratory failure
• Coagulopathy
• Sepsis
• Liver failure
• Hypotension
• Renal Failure
• Duration of Stay
• Multiple of above risk factors(burns)

8
Incidence

• Incidence and Prevalence reducing
• 1970s and 1980s 15 5
• Cooke et al- 1.5 clinically significant 2
• Incidence associated with
• Severity of illness
• Patient factors
• Duration ventilation
• Duration of ICU stay

9
Treatment

• Antacid
• Sucrulfate
• H2RA
• PPI
• Enteral nutrition
• General Measures

10
Cook et al JAMA 1996
11
Cook DJ et al New Eng j 1998
12
Treatment

• Evidence suggests that bleeding, but not
  mortality can be reduced, by all agents. 7
• Evidence suggests that H2 receptor antagonists
  are most efficient in reducing overt and
  clinically important bleeding in ICU patients.
  4
• Enteral nutrition and ranitidine protect against
  bleeding, and an additive effect is seen. 8

13
PPI

• Effectively suppresses gastric pH levels in the
  ICU patient
• PPIs superior to H2RAs for PUD and GRD
• Data extrapolated in SRMB
• Omeprazole found to be superior than ranitidine
  in preventing SRMB9
• Groups not equal regarding risk

14
PPI

• Several studies concluded agents were safe and as
  effective as an alternative to H2RA
• Small studies
• Need for further clinical trials

15
Enteral Nutrition

• Cook et al protective effect of enteral feeding
  for prevention SRMB (relative risk 0.30)8
• Inconclusive results for enteral feeding being
  used as SUP9
• Cannot be recommended as sole agent10

16
Treatment Strategy

• No current evidence that patients without 1 of 6
  major risk factors warrant prophylaxis
• Shock
• Sepsis
• Resp failure
• Hepatic failure
• Renal failure
• Coagulopathy

17
Treatment Complications

• Nosocomial pneumonia
• Anti-acid therapy promotes colonisation of gut
  mucosa
• Aspiration may cause pneumonia 611
• Sucralfate doesnt alter gastric pH
• Pnuemonia rates with ranitidine and sucralfate
  not statistically different12

18
Treatment Complications

• Nosocomial pneumonia H2RA vs PPI
• 14 patients on ranitidine developed NP
• 3 patients on omeprazole developed NP 13

19
Discussion and Questions
20
References

• 1 -    Pruitt BA, Jr., Foley FD, Moncrief JA.
  Curling's ulcer a clinical-pathology study of
  323 cases. Ann Surg 1970 172(4)523-539.
• 2   Cook DJ, Fuller HD, Guyatt GH, Marshall JC,
  Leasa D, Hall R et al. Risk factors for
  gastrointestinal bleeding in critically ill
  patients. Canadian Critical Care Trials Group. N
  Engl J Med 1994 330(6)377-381.

21
References

• 3   Skillman JJ, Bushnell LS, Goldman H, Silen
  W. Respiratory failure, hypotension, sepsis, and
  jaundice. A clinical syndrome associated with
  lethal hemorrhage from acute stress ulceration of
  the stomach. Am J Surg 1969 117(4)523-530.
• 4 Cook D, Guyatt G, Marshall J, Leasa D, Fuller
  H, Hall R et al. A comparison of sucralfate and
  ranitidine for the prevention of upper
  gastrointestinal bleeding in patients requiring
  mechanical ventilation. Canadian Critical Care
  Trials Group. N Engl J Med 1998 338(12)791-797.

22
References

• 5 Shuman RB, Schuster DP, Zuckerman GR.
  Prophylactic therapy for stress ulcer bleeding a
  reappraisal. Ann Intern Med 1987 106(4)562-567.
• 6 Cook DJ, Walter SD, Cook RJ, Griffith LE,
  Guyatt GH, Leasa D et al. Incidence of and risk
  factors for ventilator-associated pneumonia in
  critically ill patients. Ann Intern Med 1998
  129(6)433-440.

23
References

• 7 Cook DJ et al JAMA 1996
• 8 Cook DJ et al. Crit Care Med 1999 272812
• 9 Raff et al Burns 1997 23313-318
• 10 MacClaren et al Use of enteral nutrition
  for stress ulcer prophylaxis. Ann Pharmacother
  2001351614-1623
• 11 Tryba role of acid suppressants in
  intensive care medicine. Best Pract Res Clin
  Gastroenterol

24
References

• 12 Tryba M Sucalfate vs antacids or H2RA for
  SUP A meta-analysis on efficacy and pneumonia
  rate. Crit Care Med 19901644-49
• 13 Levy et al Comparison of omeprazole and
  ranitidine for SUP Dig Dis Sci 1997 421255-1259