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Research Article
18 May 2018

Comparing efficacy of enteral nutrition plus ranitidine and enteral nutrition alone as stress ulcer prophylaxis

Abstract

Aim: Adequacy of enteral nutrition (EN) alone as stress ulcer prophylaxis (SUP) is controversial. The aim of this study was to compare efficacy of EN alone and ranitidine plus EN as SUP. Method: Critically ill adults with indications to receive SUP were randomized to ranitidine 50 mg IV every 8 h plus EN (SUP) or EN alone (non-SUP) group for 7 days. Besides, endoscopy was performed at the time of recruitment and on day 7. Results: During the study period, only one patient in each group of SUP and non-SUP experienced gastrointestinal bleeding. At the time of recruitment, gastric erosion and erythema were the most endoscopic findings in the SUP and non-SUP groups. These findings did not significantly change at the end of the study (p = 0.21). Conclusion: EN was at least effective as ranitidine plus EN as SUP.

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References

Papers of special note have been highlighted as: • of interest; •• of considerable interest
1.
Avendaño-Reyes JM, Jaramillo-Ramírez H. Prophylaxis for stress ulcer bleeding in the intensive care unit. Rev. Gastroenterol. Mex. 79(1), 50–55 (2014).
2.
Mousavi M, Dashti-Khavidaki S, Khalili H, Farshchi A, Gatmiri M. Impact of clinical pharmacy services on stress ulcer prophylaxis prescribing and related cost in patients with renal insufficiency. Int. J. Pharm. Pract. 21(4), 263–269 (2013).
3.
Marker S, Krag M, Møller MH. What's new with stress ulcer prophylaxis in the ICU? Intensive Care Med. 43(8), 1132–1134 (2017).
•• News in stress ulcer prophylaxis (SUP) in the intensive care unit.
4.
Faust AC, Echevarria KL, Attridge RL. Prophylactic acid-suppressive therapy in hospitalized adults: indications, benefits, and infectious complications. Crit. Care Nurse 37(3), 18–29 (2017).
•• Review of acid-suppressive therapy in hospitalized adults.
5.
Hurt RT, Frazier TH, McClave SA et al. Stress prophylaxis in intensive care unit patients and the role of enteral nutrition. JPEN J. Parenter. Enteral. Nutr. 36(6), 721–731 (2012).
6.
MacLaren R, Campbell J. Cost–effectiveness of histamine receptor-2 antagonist versus proton pump inhibitor for stress ulcer prophylaxis in critically ill patients. Crit. Care Med. 42(4), 809–815 (2014).
7.
Somberg L, Morris J Jr, Fantus R et al. Intermittent intravenous pantoprazole and continuous cimetidine infusion: effect on gastric pH control in critically ill patients at risk of developing stress-related mucosal disease. J. Trauma 64(5), 1202–1210 (2008).
8.
Spirt MJ. Acid suppression in critically ill patients: what does the evidence support? Pharmacotherapy 23, 87S–93S (2003).
9.
Singh H, Houy TL, Singh N, Sekhon S. Gastrointestinal prophylaxis in critically ill patients. Crit. Care Nurs. Q. 4, 291–301 (2008).
10.
Huang J, Cao Y, Liao C, Wu L, Gao F. Effect of histamine-2-receptor antagonists versus sucralfate on stress ulcer prophylaxis in mechanically ventilated patients: a meta-analysis of 10 randomized controlled trials. Crit. Care 14(5), R194 (2010).
11.
Constantin VD, Paun S, Ciofoaia VV, Budu V, Socea B. Multimodal management of upper gastrointestinal bleeding caused by stress gastropathy. J. Gastrointestin. Liver Dis. 18(3), 279–284 (2009).
12.
Krag M, Perner A, Wetterslev J. Stress ulcer prophylaxis in the intensive care unit trial: detailed statistical analysis plan. Acta Anaesthesiol. Scand. 61(7), 859–868 (2017).
13.
Lat I, Micek S, Janzen J. Off-label medication use in adult critical care patients. J. Crit. Care 26(1), 89–94 (2011).
14.
Cook DJ, Fuller HD, Guyatt GH. Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N. Engl. J. Med. 330(6), 377–381 (1994).
15.
Krag M1, Perner A, Møller MH. Stress ulcer prophylaxis in the intensive care unit. Curr. Opin. Crit. Care. 22(2), 186–190 (2016).
16.
Selvanderan SP, Summers MJ, Finnis ME. Pantoprazole Or Placebo for stress Ulcer Prophylaxis (POP-UP): randomized double-blind exploratory study. Critical Care Med. 44(10), 1842–1850 (2016).
• Pantoprazole or placebo for SUP.
17.
Buendgens L, Koch A, Tacke F. Prevention of stress-related ulcer bleeding at the intensive care unit: risks and benefits of stress ulcer prophylaxis. World J. Crit. Care Med. 5(1), 57–64 (2016).
• Risks and benefits of SUP.
18.
Björne H, Govoni M, Törnberg DC. Intragastric nitric oxide is abolished in intubated patients and restored by nitrite. Crit. Care Med. 33(8), 1722–1727 (2005).
19.
Bardou M, Quenot JP, Barkun A. Stress-related mucosal disease in the critically ill patient. Nat. Rev. Gastroenterol. Hepatol. 12(2), 98–107 (2015).
20.
Tabeefar H, Beigmohammadi MT, Javadi MR et al. Effects of pantoprazole on systemic and gastric pro- and anti-inflammatory cytokines in critically ill patients. Iran J. Pharm. Res. 11(4), 1051–1058 (2012).
21.
Martindale RG. Contemporary strategies for the prevention of stress-related mucosal bleeding. Am. J. Health Syst. Pharm. 62(10 Suppl. 2), S11–S17 (2005).
22.
Palm NM, McKinzie B, Ferguson PL et al. Pharmacologic stress gastropathy prophylaxis may not be necessary in at-risk surgical trauma icu patients tolerating enteral nutrition. J. Intensive Care Med. pii:0885066616678385 (2016) (Epub ahead of print).
23.
Krag M, Perner A, Wetterslev J. Stress ulcer prophylaxis in the intensive care unit: an international survey of 97 units in 11 countries. Acta Anaesthesiol. Scand. 59(5), 576–585 (2015).
24.
Plummer MP, Blaser AR, Deane AM. Stress ulceration: prevalence, pathology and association with adverse outcomes. Crit. Care 18(2), 213 (2014).
25.
Ali T, Harty RF. Stress-induced ulcer bleeding in critically ill patients. Gastroenterol. Clin. North Am. 38(2), 245–265 (2009).
26.
Brophy GM, Brackbill ML, Bidwell KL. Prospective, randomized comparison of lansoprazole suspension, and intermittent intravenous famotidine on gastric pH and acid production in critically ill neurosurgical patients. Neurocrit. Care 13, 176–181 (2010).
27.
ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis. ASHP Commission on Therapeutics and approved by the ASHP Board of Directors on November 14, 1998. Am. J. Health Syst. Pharm. 56, 347–379 (1999).
28.
Khalili H, Dashti-Khavidaki S, Haj Hossein Talasaz A. Descriptive analysis of a clinical pharmacy intervention to improve the appropriate use of stress ulcer prophylaxis in a hospital infectious disease ward. J. Manag. Care Pharm. 16(2), 114–121 (2010).
29.
Marker S, Perner A, Wetterslev J et al. Stress ulcer prophylaxis versus placebo or no prophylaxis in adult hospitalised acutely ill patients; protocol for a systematic review with meta-analysis and trial sequential analysis. Syst. Rev. 6(1), 118 (2017).
30.
Heyland DK, Dhaliwal R, Drover JW. Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J. Perenter. Enteral Nutr. 27, 355–373 (2003).
31.
Pilkington KB, Wagstaff MJ, Greenwood JE. Prevention of gastrointestinal bleeding due to stress ulceration: a review of current literature. Anaesth. Intensive Care 40, 253–259 (2012).
32.
Lenz K, Buder R, Firlinger F, Lohr G, Voglmayr M. Effect of proton pump inhibitors on gastric pH in patients exposed to severe stress. Wien Klin. Wochenschr. 127, 51–56 (2015).
33.
Khorvash F, Abbasi S, Meidani M, Dehdashti F, Ataei B. The comparison between proton pump inhibitors and sucralfate in incidence of ventilator associated pneumonia in critically ill patients. Adv. Biomed. Res. 3, 52 (2014).
34.
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 136(2), 440–447 (2009).
35.
Frandah W, Colmer-Hamood J, Mojazi Amiri H, Raj R, Nugent K. Oropharyngeal flora in patients admitted to the medical intensive care unit: clinical factors and acid suppressive therapy. J. Med. Microbiol. 62, 778–784 (2013).
36.
Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA 301, 2120–2128 (2009).
37.
Anbar R. Enteral nutrition. World Rev. Nutr. Diet 105, 50–58 (2013).
38.
Lu T, Guan J. Combined application of nasogastric tubes and nasointestinal tubes in neurosurgical intensive care patients with stress ulceration: a novel solution to treatment and early enteral nutrition. Springer Plus 5(1), 1769 (2016).
39.
Kreymann K, Berger M, Deutz N. ESPEN guidelines on enteral nutrition: intensive care. Clin. Nutr. 25, 210–223 (2006).
40.
Bonten MJ, Gaillard CA, van Tiel FH. Continuous enteral nutrition counteracts preventative measures for gastric colonisation in intensive care patients. Crit. Care Med. 22, 939–944 (1994).
41.
MacLaren R, Jarvis CL, Fish DN. Use of enteral nutrition for stress ulcer prophylaxis. Ann. Pharmacother. 35(12), 1614–1623 (2001).
42.
Piriyapatsom A, Lin H, Pirrone M et al. Evaluation of the infection-related ventilator-associated events algorithm for ventilator-associated pneumonia surveillance in a trauma population. Respir. Care 61(3), 269–276 (2016).
43.
Rhodes A, Evans LE, Alhazzani W et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 43(3), 304–377 (2017).
44.
Garrow JS, James WPT, Ralph A. Human Nutrition and Dietetics. 10th Edition. Churchill Livingstone, Edinburgh, UK (2000).
45.
Faisy C, Guerot E, Diehl JL. Clinically significant gastrointestinal bleeding in critically ill patients with and without stress-ulcer prophylaxis. Intensive Care Med. 29(8), 1306–1313 (2003).
46.
Kompan L, Kremzar B, Gadzijev E. Effects of early enteral nutrition on intestinal permeability and the development of multiple organ failure after multiple injury. Intensive Care Med. 25, 157–161 (1999).
47.
Fan M, Wang Q, Fang W et al. Early enteral combined with parenteral nutrition treatment for severe traumatic brain injury: effects on immune function, nutritional status and outcomes. Chin. Med. Sci. J. 31(4), 213–220 (2016).
48.
Pingleton SK, Hadzima SK. Enteral alimentation and gastrointestinal bleeding in mechanically ventilated patients. Crit. Care Med. 11(1), 13–16 (1983).
49.
El-Kersh K, Jalil B, McClave SA et al. Enteral nutrition as stress ulcer prophylaxis in critically ill patients: a randomized controlled exploratory study. J. Crit. Care 43, 108–113 (2017).
50.
Gurman G, Samri M, Sarov B. The rate of gastrointestinal bleeding in a general ICU population: a retrospective study. Intensive Care Med. 16, 44–49 (1990).
51.
Raff T, Germann G, Hartmann B. The value of early enteral nutrition in the prophylaxis of stress ulceration in the severely burned patient. Burns 23(4), 313–318 (1997).
52.
Cinotti R, Dordonnat-Moynard A, Feuillet F et al. Risk factors and pathogens involved in early ventilator-acquired pneumonia in patients with severe subarachnoid hemorrhage. Eur. J. Clin. Microbiol. Infect. Dis. 33, 823–830 (2014).
53.
Albert BD, Zurakowski D, Bechard LJ et al. Enteral nutrition and acid-suppressive therapy in the PICU: impact on the risk of ventilator-associated pneumonia. Pediatr. Crit. Care Med. 17(10), 924–929 (2016).
54.
Marik PE, Vasu T, Hirani A. Stress ulcer prophylaxis in the new millennium: a systematic review and meta-analysis. Crit. Care Med. 38(11), 2222–2228 (2010).
55.
Jump RL, Pultz MJ, Donskey CJ. Vegetative Clostridium difficile survives in room air on moist surfaces and in gastric contents with reduced acidity: a potential mechanism to explain the association between proton pump inhibitors and C. difficile-associated diarrhea? Antimicrob. Agents Chemother. 51(8), 2883–2887 (2007).