Intensive Care Medicine

, Volume 32, Issue 8, pp 1151–1158

Stress ulcer prophylaxis in mechanically ventilated patients: integrating evidence and judgment using a decision analysis

  • Jeremy M. Kahn
  • Jason N. Doctor
  • Gordon D. Rubenfeld
Original

Abstract

Objective

Stress ulcer prophylaxis with a histamine-2 receptor antagonist can reduce the risk of gastrointestinal bleeding in mechanically ventilated patients but may also increase the risk of ventilator-associated pneumonia. We sought to clarify the tradeoffs involved in selecting a prophylactic strategy.

Design

Decision analysis.

Patients and participants

A decision tree was constructed for a hypothetical cohort of patients receiving mechanical ventilation for an expected duration of longer than 48 h, using probabilities estimated from the published literature.

Interventions

Patients in the model could receive either prophylaxis with a histamine-2 receptor antagonist or no prophylaxis. Sensitivity analyses were preformed varying the estimated probabilities over their plausible ranges.

Measurements and results

Both strategies were associated with approximately the same baseline expected mortality (16.6% for histamine-2 receptor antagonists and 16.9% for no prophylaxis, risk difference 0.3%). Varying the estimated probabilities resulted in only small changes in both the expected mortality and the absolute risk reduction associated with the preferred treatment. At the extremes of assumptions the absolute mortality reduction ranged from 0.1% to 3.3%.

Conclusions

No single strategy of stress ulcer prophylaxis is preferred when mortality is used as the outcome. In the absence of a clinical trial demonstrating survival benefit the individual clinician's assumptions regarding the effect of prophylaxis on gastrointestinal bleeding and pneumonia and the attributable mortality of pneumonia vs. gastrointestinal bleeding will have a significant effect on the decision.

Keywords

Critical care Intensive care Gastrointestinal hemorrhage Pneumonia Nosocomial infections 

References

  1. 1.
    Steinberg KP (2002) Stress-related mucosal disease in the critically ill patient: risk factors and strategies to prevent stress-related bleeding in the intensive care unit. Crit Care Med 30:S362–364PubMedCrossRefGoogle Scholar
  2. 2.
    Cook DJ, Reeve BK, Guyatt GH, Heyland DK, Griffith LE, Buckingham L, Tryba M (1996) Stress ulcer prophylaxis in critically ill patients. Resolving discordant meta-analyses. JAMA 275:308–314PubMedCrossRefGoogle Scholar
  3. 3.
    Messori A, Trippoli S, Vaiani M, Gorini M, Corrado A (2000) Bleeding and pneumonia in intensive care patients given ranitidine and sucralfate for prevention of stress ulcer: meta-analysis of randomised controlled trials. BMJ 321:1103–1106PubMedCrossRefGoogle Scholar
  4. 4.
    Erstad BL, Barletta JF, Jacobi J, Killian AD, Kramer KM, Martin SJ (1999) Survey of stress ulcer prophylaxis. Crit Care (Lond) 3:145–149CrossRefGoogle Scholar
  5. 5.
    Lam NP, Le PD, Crawford SY, Patel S (1999) National survey of stress ulcer prophylaxis. Crit Care Med 27:98–103PubMedCrossRefGoogle Scholar
  6. 6.
    Daley RJ, Rebuck JA, Welage LS, Rogers FB (2004) Prevention of stress ulceration: current trends in critical care. Crit Care Med 32:2008–2013PubMedCrossRefGoogle Scholar
  7. 7.
    Cook DJ, Kollef MH (1998) Risk factors for ICU-acquired pneumonia. JAMA 279:1605–1606PubMedCrossRefGoogle Scholar
  8. 8.
    Chastre J, Fagon J-Y (2002) Ventilator-associated Pneumonia. Am J Respir Crit Care Med 165:867–903PubMedGoogle Scholar
  9. 9.
    Collard HR, Saint S, Matthay MA (2003) Prevention of ventilator-associated pneumonia: an evidence-based systematic review. Ann Intern Med 138:494–501PubMedGoogle Scholar
  10. 10.
    Hubmayr RD, Burchardi H, Elliot M, Fessler H, Georgopoulos D, Jubran A, Limper A, Pesenti A, Rubenfeld G, Stewart T, Villar J (2002) Statement of the 4th International Consensus Conference in Critical Care on ICU-Acquired Pneumonia-Chicago, Illinois, May 2002. Intensive Care Med 28:1521–1536PubMedCrossRefGoogle Scholar
  11. 11.
    Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, Muscedere J, Foster D, Mehta N, Hall R, Brun-Buisson C (2004) Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med 141:305–313PubMedGoogle Scholar
  12. 12.
    American Thoracic Society (2005) Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 171:388–416CrossRefGoogle Scholar
  13. 13.
    Dressler DD, Williams MV, Rask KM (2001) Prevention of clinically significant gastrointenstinal bleeding in intensive care unit patients. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM (eds) Making health care safer: a critical analysis of patient safety practices. Agency for Healthcare Research and Quality, RockvilleGoogle Scholar
  14. 14.
    Pitimana-aree S, Forrest D, Brown G, Anis A, Wang XH, Dodek P (1998) Implementation of a clinical practice guideline for stress ulcer prophylaxis increases appropriateness and decreases cost of care. Intensive Care Med 24:217–223PubMedCrossRefGoogle Scholar
  15. 15.
    Anonymous (2004) Ventilator bundle (IHI tool). BMJ available at: http://www.ihi.org, accessed 10 March 2005Google Scholar
  16. 16.
    Joint Commission on Accreditation of Healthcare Organizations (2005) Specifications manual for national hospital quality measures, ICU, version 1.0Google Scholar
  17. 17.
    Rubenfeld GD (2001) Understanding why we agree on the evidence but disagree on the medicine. Respir Care 46:1442–1449PubMedGoogle Scholar
  18. 18.
    Ruiz-Santana S, Ortiz E, Gonzalez B, Bolanos J, Ruiz-Santana AJ, Manzano JL (1991) Stress-induced gastroduodenal lesions and total parenteral nutrition in critically ill patients: frequency, complications, and the value of prophylactic treatment. A prospective, randomized study. Crit Care Med 19:887–891PubMedCrossRefGoogle Scholar
  19. 19.
    Cook D, Guyatt G, Marshall J, Leasa D, Fuller H, Hall R, Peters S, Rutledge F, Griffith L, McLellan A, Wood G, Kirby A (1998) 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 338:791–797PubMedCrossRefGoogle Scholar
  20. 20.
    Yildizdas D, Yapicioglu H, Yilmaz HL (2002) Occurrence of ventilator-associated pneumonia in mechanically ventilated pediatric intensive care patients during stress ulcer prophylaxis with sucralfate, ranitidine, and omeprazole. J Crit Care 17:240–245PubMedCrossRefGoogle Scholar
  21. 21.
    Kantorova I, Svoboda P, Scheer P, Doubek J, Rehorkova D, Bosakova H, Ochmann J (2004) Stress ulcer prophylaxis in critically ill patients: a randomized controlled trial. Hepatogastroenterology 51:757–761PubMedGoogle Scholar
  22. 22.
    Conrad SA, Gabrielli A, Margolis B, Quartin A, Hata JS, Frank WO, Bagin RG, Rock JA, Hepburn B, Laine L (2005) Randomized, double-blind comparison of immediate-release omeprazole oral suspension versus intravenous cimetidine for the prevention of upper gastrointestinal bleeding in critically ill patients. Crit Care Med 33:760–765PubMedCrossRefGoogle Scholar
  23. 23.
    Cook DJ, Fuller HD, Guyatt GH, Marshall JC, Leasa D, Hall R, Winton TL, Rutledge F, Todd TJ, Roy P et al (1994) Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J Med 330:377–381PubMedCrossRefGoogle Scholar
  24. 24.
    Zandstra DF, Stoutenbeek CP (1994) 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 20:335–340PubMedCrossRefGoogle Scholar
  25. 25.
    Pimentel M, Roberts DE, Bernstein CN, Hoppensack M, Duerksen DR (2000) Clinically significant gastrointestinal bleeding in critically ill patients in an era of prophylaxis. Am J Gastroenterol 95:2801–2806PubMedCrossRefGoogle Scholar
  26. 26.
    Cook DJ, Griffith LE, Walter SD, Guyatt GH, Meade MO, Heyland DK, Kirby A, Tryba M (2001) The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients. Crit Care 5:368–375PubMedCrossRefGoogle Scholar
  27. 27.
    Faisy C, Guerot E, Diehl JL, Iftimovici E, Fagon JY (2003) Clinically significant gastrointestinal bleeding in critically ill patients with and without stress-ulcer prophylaxis. Intensive Care Med 29:1306–1313PubMedCrossRefGoogle Scholar
  28. 28.
    Maury E, Tankovic J, Ebel A, Offenstadt G (2005) An observational study of upper gastrointestinal bleeding in intensive care units: is Helicobacter pylori the culprit? Crit Care Med 33:1513–1518PubMedCrossRefGoogle Scholar
  29. 29.
    Joshi N, Localio AR, Hamory BH (1992) A predictive risk index for nosocomial pneumonia in the intensive care unit. Am J Med 93:135–142PubMedCrossRefGoogle Scholar
  30. 30.
    Cook DJ, Walter SD, Cook RJ, Griffith LE, Guyatt GH, Leasa D, Jaeschke RZ, Brun-Buisson C (1998) Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med 129:433–440PubMedGoogle Scholar
  31. 31.
    Torres A, Aznar R, Gatell JM, Jimenez P, Gonzalez J, Ferrer A, Celis R, Rodriguez-Roisin R (1990) Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patients. Am Rev Respir Dis 142:523–528PubMedGoogle Scholar
  32. 32.
    Rello J, Quintana E, Ausina V, Castella J, Luquin M, Net A, Prats G (1991) Incidence, etiology, and outcome of nosocomial pneumonia in mechanically ventilated patients. Chest 100:439–444PubMedCrossRefGoogle Scholar
  33. 33.
    Fagon JY, Chastre J, Hance AJ, Montravers P, Novara A, Gibert C (1993) Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. Am J Med 94:281–288PubMedCrossRefGoogle Scholar
  34. 34.
    Kollef MH (1993) Ventilator-associated pneumonia. A multivariate analysis. JAMA 270:1965–1970PubMedCrossRefGoogle Scholar
  35. 35.
    Kollef MH, Silver P, Murphy DM, Trovillion E (1995) The effect of late-onset ventilator-associated pneumonia in determining patient mortality. Chest 108:1655–1662PubMedCrossRefGoogle Scholar
  36. 36.
    George DL, Falk PS, Wunderink RG, Leeper KV Jr, Meduri GU, Steere EL, Corbett CE, Glen Mayhall C (1998) Epidemiology of Ventilator-acquired Pneumonia Based on Protected Bronchoscopic Sampling. Am J Respir Crit Care Med 158:1839–1847PubMedGoogle Scholar
  37. 37.
    Heyland DK, Cook DJ, Griffith L, Keenan SP, Brun-Buisson C (1999) The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Critical Trials Group. Am J Respir Crit Care Med 159:1249–1256PubMedGoogle Scholar
  38. 38.
    Leroy O, Guilley J, Georges H, Choisy P, Guery B, Alfandari S, Beaucaire G (1999) Effect of hospital-acquired ventilator-associated pneumonia on mortality of severe community-acquired pneumonia. J Crit Care 14:12–19PubMedCrossRefGoogle Scholar
  39. 39.
    Markowicz P, Wolff M, Djedaini K, Cohen Y, Chastre J, Delclaux C, Merrer J, Herman B, Veber B, Fontaine A, Dreyfuss D (2000) Multicenter prospective study of ventilator-associated pneumonia during acute respiratory distress syndrome. Incidence, prognosis, and risk factors. ARDS Study Group. Am J Respir Crit Care Med 161:1942–1948PubMedGoogle Scholar
  40. 40.
    Ibrahim EH, Tracy L, Hill C, Fraser VJ, Kollef MH (2001) The occurrence of ventilator-associated pneumonia in a community hospital: risk factors and clinical outcomes. Chest 120:555–561PubMedCrossRefGoogle Scholar
  41. 41.
    Critchfield GC, Willard KE (1986) Probabilistic analysis of decision trees using Monte Carlo simulation. Med Decis Making 6:85–92PubMedCrossRefGoogle Scholar
  42. 42.
    Tversky A, Kahneman D (1974) Judgement under uncertainty: heuristics and biases. Science 185:1124–1131PubMedCrossRefGoogle Scholar
  43. 43.
    Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS (1996) Evidence based medicine: what it is and what it isn't. BMJ 312:71–72PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  • Jeremy M. Kahn
    • 1
  • Jason N. Doctor
    • 2
  • Gordon D. Rubenfeld
    • 1
  1. 1.Division of Pulmonary and Critical Care MedicineHarborview Medical CenterSeattleUSA
  2. 2.Department of Medical Education and Biomedical InformaticsUniversity of WashingtonSeattleUSA

Personalised recommendations