Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Critical Care
Published in: Critical Care 1/2018

Open Access 01-12-2018 | Research

Stress ulcer prophylaxis in intensive care unit patients receiving enteral nutrition: a systematic review and meta-analysis

Authors: Hui-Bin Huang, Wei Jiang, Chun-Yao Wang, Han-Yu Qin, Bin Du

Published in: Critical Care | Issue 1/2018

Login to get access

Abstract

Background

Pharmacologic stress ulcer prophylaxis (SUP) is recommended in critically ill patients with high risk of stress-related gastrointestinal (GI) bleeding. However, as to patients receiving enteral feeding, the preventive effect of SUP is not well-known. Therefore, we performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of pharmacologic SUP in enterally fed patients on stress-related GI bleeding and other clinical outcomes.

Methods

We searched PubMed, Embase, and the Cochrane database from inception through 30 Sep 2017. Eligible trials were RCTs comparing pharmacologic SUP to either placebo or no prophylaxis in enterally fed patients in the ICU. Results were expressed as risk ratio (RR) and mean difference (MD) with accompanying 95% confidence interval (CI). Heterogeneity, subgroup analysis, sensitivity analysis and publication bias were explored.

Results

Seven studies (n = 889 patients) were included. There was no statistically significant difference in GI bleeding (RR 0.80; 95% CI, 0.49 to 1.31, p = 0.37) between groups. This finding was confirmed by further subgroup analyses and sensitivity analysis. In addition, SUP had no effect on overall mortality (RR 1.21; 95% CI, 0.94 to 1.56, p = 0.14), Clostridium difficile infection (RR 0.89; 95% CI, 0.25 to 3.19, p = 0.86), length of stay in the ICU (MD 0.04 days; 95% CI, −0.79 to 0.87, p = 0.92), duration of mechanical ventilation (MD −0.38 days; 95% CI, −1.48 to 0.72, p = 0.50), but was associated with an increased risk of hospital-acquired pneumonia (RR 1.53; 95% CI, 1.04 to 2.27; p = 0.03).

Conclusions

Our results suggested that in patients receiving enteral feeding, pharmacologic SUP is not beneficial and combined interventions may even increase the risk of nosocomial pneumonia.
Appendix
Available only for authorised users
Literature
1.
Krag M, Perner A, Wetterslev J, Wise MP, Borthwick M, Bendel S, McArthur C, Cook D, Nielsen N, Pelosi P, et al. Stress ulcer prophylaxis in the intensive care unit: an international survey of 97 units in 11 countries. Acta Anaesthesiol Scand. 2015;59(5):576–85.CrossRefPubMed
2.
Faisy C, Guerot E, Diehl JL, Iftimovici E, Fagon JY. Clinically significant gastrointestinal bleeding in critically ill patients with and without stress-ulcer prophylaxis. Intensive Care Med. 2003;29(8):1306–13.CrossRefPubMed
3.
Zandstra DF, Stoutenbeek CP. The virtual absence of stress-ulceration related bleeding in ICU patients receiving prolonged mechanical ventilation without any prophylaxis. A prospective cohort study. Intensive Care Med. 1994;20(5):335–40.CrossRefPubMed
4.
Marik PE, Vasu T, Hirani A, Pachinburavan M. Stress ulcer prophylaxis in the new millennium: a systematic review and meta-analysis. Crit Care Med. 2010;38(11):2222–28.CrossRefPubMed
5.
Guillamondegui OD, Gunter OL Jr, Bonadies JA, Coates JE, Kurek SJ, De Moya MA, Sing RF, Sori AJ. Practice management guidelines for stress ulcer prophylaxis. Chicago: Eastern Association for the Surgery of Trauma. 2008:1–24.
6.
7.
Daley RJ, Rebuck JA, Welage LS, Rogers FB. Prevention of stress ulceration: current trends in critical care. Crit Care Med. 2004;32(10):2008.CrossRefPubMed
8.
Eastwood GM, Litton E, Bellomo R, Bailey MJ, Festa M, Beasley RW, Young PJ. Opinions and practice of stress ulcer prophylaxis in Australian and New Zealand intensive care units. Crit Care Resusc. 2014;16(3):170–74.PubMed
9.
Shears M, Alhazzani W, Marshall JC, Muscedere J, Hall R, English SW, Dodek PM, Lauzier F, Kanji S, Duffett M, et al. Stress ulcer prophylaxis in critical illness: a Canadian survey. Can J Anaesth. 2016;63(6):718–24.CrossRefPubMed
10.
Farley KJ, Barned KL, Crozier TM. Inappropriate continuation of stress ulcer prophylaxis beyond the intensive care setting. Crit Care Resusc. 2013;15(2):147–51.PubMed
11.
Miano TA, Reichert MG, Houle TT, Macgregor DA, Kincaid EH, Bowton DL. Nosocomial pneumonia risk and stress ulcer prophylaxis: a comparison of pantoprazole vs ranitidine in cardiothoracic surgery patients. Chest. 2009;136(2):440.CrossRefPubMed
12.
Azab M, Doo L, Doo DH, Elmofti Y, Ahmed M, Cadavona JJ, Liu XB, Shafi A, Joo MK, Yoo JW. Comparison of the hospital-acquired clostridium difficile infection risk of using proton pump inhibitors versus histamine-2 receptor antagonists for prophylaxis and treatment of stress ulcers: a systematic review and meta-analysis. Gut Liver. 2017;11(6):781–8.CrossRefPubMedPubMedCentral
13.
Leonard J, Marshall JK, Moayyedi P. Systematic review of the risk of enteric infection in patients taking acid suppression. Am J Gastroenterol. 2007;102(9):2047–56. quiz 2057.CrossRefPubMed
14.
Pingleton SK, Hadzima SK. Enteral alimentation and gastrointestinal bleeding in mechanically ventilated patients. Crit Care Med. 1983;11(1):13.CrossRefPubMed
15.
Ephgrave KS, Kleimanwexler RL, Adair CG. Enteral nutrients prevent stress ulceration and increase intragastric volume. Crit Care Med. 1990;18(6):621.CrossRefPubMed
16.
Inoue S, Lukes S, Alexander JW, Trocki O, Silberstein EB. Increased gut blood flow with early enteral feeding in burned guinea pigs. J Burn Care Rehabil. 1989;10(4):300.CrossRefPubMed
17.
Bonten MJ, Gaillard CA, van Tiel FH, van der Geest S, Stobberingh EE. Continuous enteral feeding counteracts preventive measures for gastric colonization in intensive care unit patients. Crit Care Med. 1994;22(6):939–44.CrossRefPubMed
18.
Alhazzani W, Guyatt G, Alshahrani M, Deane AM, Marshall JC, Hall R, Muscedere J, English SW, Lauzier F, Thabane L, et al. Withholding pantoprazole for stress ulcer prophylaxis in critically ill patients: a pilot randomized clinical trial and meta-analysis. Crit Care Med. 2017;45(7):1121–29.CrossRefPubMed
19.
Krag M, Perner A, Wetterslev J, Wise MP, Hylander MM. Stress ulcer prophylaxis versus placebo or no prophylaxis in critically ill patients. A systematic review of randomised clinical trials with meta-analysis and trial sequential analysis. Intensive Care Med. 2014;40(1):11–22.CrossRefPubMed
20.
Alhazzani W, Alenezi F, Jaeschke RZ, Moayyedi P, Cook DJ. Proton pump inhibitors versus histamine 2 receptor antagonists for stress ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis. Crit Care Med. 2013;41(3):693–705.CrossRefPubMed
21.
Apte NM, Karnad DR, Medhekar TP, Tilve GH, Morye S, Bhave GG. Gastric colonization and pneumonia in intubated critically ill patients receiving stress ulcer prophylaxis: a randomized, controlled trial. Crit Care Med. 1992;20(5):590–93.CrossRefPubMed
22.
Benmenachem T, Fogel R, Patel RV, Touchette M, Zarowitz BJ, Hadzijahic N, Divine G, Verter J, Bresalier RS. Prophylaxis for stress-related gastric hemorrhage in the medical intensive care unit. A randomized, controlled, single-blind study. Ann Intern Med. 1994;121(8):568–75.CrossRef
23.
Berg BVD, Blankenstein MV. Prevention of stress-induced upper gastrointestinal bleeding by cimetidine in patients on assisted ventilation. Digestion. 1985;31(1):1.CrossRefPubMed
24.
Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8(5):336–41.CrossRefPubMed
25.
Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, Savović J, Schulz KF, Weeks L, Sterne JAC. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.CrossRefPubMedPubMedCentral
26.
Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol. 2014;14(1):135.CrossRefPubMedPubMedCentral
27.
Selvanderan SP, Summers MJ, Finnis ME, Plummer MP, Ali Abdelhamid Y, Anderson MB, Chapman MJ, Rayner CK, Deane AM. Pantoprazole or placebo for stress ulcer prophylaxis (POP-UP): randomized double-blind exploratory study. Crit Care Med. 2016;44(10):1842–50.CrossRefPubMed
28.
Lin CC, Hsu YL, Chung CS, Lee TH. Stress ulcer prophylaxis in patients being weaned from the ventilator in a respiratory care center: a randomized control trial. J Formos Med Assoc. 2016;115(1):19–24.CrossRefPubMed
29.
El-Kersh K, Jalil B, McClave SA, Cavallazzi R, Guardiola J, Guilkey K, Persaud AK, Furmanek SP, Guinn BE, Wiemken TL, et al. Enteral nutrition as stress ulcer prophylaxis in critically ill patients: a randomized controlled exploratory study. J Crit Care. 2017;43:108–13.CrossRefPubMed
30.
Fiddian-Green RG, Mcgough E, Pittenger G, Rothman E. Predictive value of intramural pH and other risk factors for massive bleeding from stress ulceration. Gastroenterology. 1983;85(3):613–20.PubMed
31.
Kazamias P, Kotzampassi K, Koufogiannis D, Eleftheriadis E. Influence of enteral nutrition-induced splanchnic hyperemia on the septic origin of splanchnic ischemia. World J Surg. 1998;22(1):6–11.CrossRefPubMed
32.
Braga M, Gianotti L, Gentilini O, Parisi V, Salis C, Di CV. Early postoperative enteral nutrition improves gut oxygenation and reduces costs compared with total parenteral nutrition. Crit Care Med. 2001;29(2):242.CrossRefPubMed
33.
Watson LC, Abston S. Prevention of upper gastrointestinal hemorrhage in 582 burned children. Am J Surg. 1976;132(6):790–93.CrossRefPubMed
34.
File Jr TM. Recommendations for treatment of hospital-acquired and ventilator-associated pneumonia: review of recent international guidelines. Clin Infect Dis. 2010;51 Suppl 1:S42–7.CrossRefPubMed
35.
Barletta JF, Erstad BL, Fortune JB. Stress ulcer prophylaxis in trauma patients. Crit Care. 2002;6(6):1–5.CrossRef
36.
Barkun AN, Bardou M, Pham CQ, Martel M. Proton pump inhibitors vs. histamine 2 receptor antagonists for stress-related mucosal bleeding prophylaxis in critically ill patients: a meta-analysis. Am J Gastroenterol. 2012;107(4):507–20.CrossRefPubMed
37.
Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, Kumar A, Sevransky JE, Sprung CL, Nunnally ME, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017;43(3):304–77.CrossRefPubMed
38.
Krag M, Perner A, Wetterslev J, Wise MP, Borthwick M, Bendel S, Pelosi P, Keus F, Guttormsen AB, Schefold JC, et al. Stress ulcer prophylaxis with a proton pump inhibitor versus placebo in critically ill patients (SUP-ICU trial): study protocol for a randomised controlled trial. Trials. 2016;17(1):205.CrossRefPubMedPubMedCentral
39.
Krag M, Perner A, Wetterslev J, Lange T, Wise MP, Borthwick M, Bendel S, Pelosi P, Keus F, Guttormsen AB, et al. Stress ulcer prophylaxis in the intensive care unit trial: detailed statistical analysis plan. Acta Anaesthesiol Scand. 2017;61(7):859–68.CrossRefPubMed
40.
Metadata
Title
Stress ulcer prophylaxis in intensive care unit patients receiving enteral nutrition: a systematic review and meta-analysis
Authors
Hui-Bin Huang
Wei Jiang
Chun-Yao Wang
Han-Yu Qin
Bin Du
Publication date
01-12-2018
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2018
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-017-1937-1

Other articles of this Issue 1/2018

Critical Care 1/2018 Go to the issue

Research

The glucocorticoid receptor and cortisol levels in pediatric septic shock

Research

Feasibility and reliability of frailty assessment in the critically ill: a systematic review

Research

Reassessing access to intensive care using an estimate of the population incidence of critical illness

Research

Carbon dioxide dynamics in relation to neurological outcome in resuscitated out-of-hospital cardiac arrest patients: an exploratory Target Temperature Management Trial substudy

Letter

Comparing fiberoptic bronchoscopy- and a tracheal tube-mounted camera-guided percutaneous dilatational tracheostomy

Research

Identification of a transcriptome profile associated with improvement of organ function in septic shock patients after early supportive therapy