Allen Michelle E, Kopp Brian J, Erstad Brian L
Adult Critical Care, Shands at the University of Florida, Gainesville, USA.
Am J Health Syst Pharm. 2004 Mar 15;61(6):588-96. doi: 10.1093/ajhp/61.6.588.
The implications of recent studies for guidelines that pertain to stress ulcer prophylaxis in the postoperative period are discussed.
The therapeutic guidelines on stress ulcer prophylaxis published by the American Society of Health-System Pharmacists (ASHP) provided clinicians with recommendations regarding appropriate candidates for stress ulcer prophylaxis and selection of a pharmacologic agent. Since these guidelines were published in 1999, additional research has been completed to resolve some of the controversial issues surrounding stress ulcer prophylaxis. The frequency of stress-induced bleeding in recent investigations continues to be highly variable, depending on the definition used to describe bleeding. In general, investigations that evaluate overt bleeding or bleeding without hemodynamic changes or blood transfusion report higher frequencies of bleeding than those that evaluate clinically important bleeding. Similar to that reported in the initial ASHP guidelines, the frequency of clinically important bleeding in recent investigations is low. In addition, the majority of recently published prospective studies and a meta-analysis have been unable to demonstrate a reduction in clinically important bleeding with pharmacologic agents. As a result, some experts have suggested that advances in critical care are more influential in the development of stress-induced bleeding than the use of pharmacologic agents. Recently published investigations support the effectiveness of institution-specific guidelines to help clinicians identify appropriate candidates for stress ulcer prophylaxis. The selection of an optimal pharmacologic agent for stress ulcer prophylaxis continues to be debated. The majority of recent studies have involved the administration of proton-pump inhibitors (PPIs). In general, these studies have demonstrated that PPIs are at least as effective as histamine H2-receptor antagonists at increasing gastric pH, but adequately powered studies investigating the endpoint of clinically important bleeding are needed. Similar to the initial ASHP guidelines, the development of institution-specific guidelines is recommended to identify the most appropriate pharmacologic treatment.
The frequency of clinically important bleeding reported in recent studies is low. The majority of recently published prospective studies and meta-analyses found little significant reduction in bleeding with pharmacologic prophylaxis.
探讨近期研究对术后应激性溃疡预防指南的影响。
美国卫生系统药师协会（ASHP）发布的应激性溃疡预防治疗指南为临床医生提供了关于应激性溃疡预防合适人选及药物选择的建议。自1999年这些指南发布以来，已完成了更多研究以解决围绕应激性溃疡预防的一些争议问题。近期调查中应激性出血的发生率仍然高度可变，这取决于用于描述出血的定义。一般来说，评估显性出血或无血流动力学变化或输血的出血的调查所报告的出血发生率高于评估具有临床意义出血的调查。与最初的ASHP指南中所报告的情况类似，近期调查中具有临床意义出血的发生率较低。此外，大多数最近发表的前瞻性研究和一项荟萃分析未能证明使用药物可减少具有临床意义的出血。因此，一些专家认为重症监护的进展在应激性出血的发生中比使用药物更具影响力。最近发表的调查支持制定机构特定指南以帮助临床医生识别应激性溃疡预防的合适人选。应激性溃疡预防最佳药物的选择仍在争论中。最近的大多数研究涉及质子泵抑制剂（PPI）的使用。一般来说，这些研究表明PPI在提高胃pH值方面至少与组胺H2受体拮抗剂一样有效，但需要有足够样本量的研究来调查具有临床意义出血这一终点。与最初的ASHP指南类似，建议制定机构特定指南以确定最合适的药物治疗。
近期研究报告的具有临床意义出血的发生率较低。大多数最近发表的前瞻性研究和荟萃分析发现药物预防在减少出血方面几乎没有显著效果。
