1 Department of Pharmacy, The Cleveland Clinic, Cleveland, OH, USA.
2 Department of Pharmacy, Medical University of South Carolina, Carolina, Charleston, SC, USA.
J Intensive Care Med. 2018 Jul;33(7):424-429. doi: 10.1177/0885066616678385. Epub 2016 Nov 11.
Stress gastropathy is a rare complication of the intensive care unit stay with high morbidity and mortality. There are data that support the concept that patients tolerating enteral nutrition have sufficient gut blood flow to obviate the need for prophylaxis; however, no robust studies exist. This study assesses the incidence of clinically significant gastrointestinal bleeding in surgical trauma intensive care unit (STICU) patients at risk of stress gastropathy secondary to mechanical ventilation receiving enteral nutrition without pharmacologic prophylaxis.
A retrospective cohort study of records from 2008 to 2013.
Adult patients in a single-center STICU were included.
Patients were included if they received full enteral nutrition while on mechanical ventilation. Exclusion criteria were coagulopathy, glucocorticoid use, prior-to-admission acid-suppressive therapy use, direct trauma or surgery to the stomach, failure to tolerate goal enteral nutrition, orders to allow natural death, and deviation from the intervention.
Pharmacologic stress ulcer prophylaxis was discontinued once enteral nutrition was providing full caloric requirements for patients requiring mechanical ventilation.
A total of 200 patients were included. The median age was 42 years, 83.0% were male, and 96.0% were trauma patients. The incidence of clinically significant gastrointestinal bleeding was 0.50%, with a subset analysis of traumatic brain injury patients yielding an incidence of 0.68%. Rates of ventilator-associated pneumonia and Clostridium difficile infection were low at 1.0 case/1000 ventilator days and 0.2 events/1000 patient days, respectively. Hospital all-cause mortality was 2.0%. Cost savings of US$121/patient stay were realized.
Stress gastropathy is rare in this population. Surgical and trauma patients at risk for stress gastropathy did not benefit from continued pharmacologic prophylaxis once they tolerated enteral nutrition. Pharmacologic prophylaxis may safely be discontinued in this patient population. Further investigation is warranted to determine whether continued prophylaxis after attaining enteral feeding goals is detrimental.
应激性胃病是重症监护病房的一种罕见并发症，具有较高的发病率和死亡率。有数据支持这样一种观点，即能够耐受肠内营养的患者有足够的肠道血流来避免预防的需要；然而，目前还没有强有力的研究存在。本研究评估了因机械通气而有应激性胃病风险的外科创伤重症监护病房（STICU）患者在接受无药物预防的肠内营养时发生临床显著胃肠道出血的发生率。
对 2008 年至 2013 年期间的记录进行回顾性队列研究。
纳入单中心 STICU 的成年患者。
如果患者在接受机械通气的同时接受全肠内营养，则将其纳入。排除标准为凝血功能障碍、糖皮质激素使用、入院前使用抑酸治疗、胃直接创伤或手术、无法耐受目标肠内营养、允许自然死亡的医嘱和干预措施偏离。
一旦肠内营养提供了机械通气患者所需的全部热量，即停止使用药物预防应激性溃疡。
共纳入 200 例患者。中位年龄为 42 岁，83.0%为男性，96.0%为创伤患者。临床显著胃肠道出血的发生率为 0.50%，创伤性脑损伤患者的亚组分析显示发生率为 0.68%。呼吸机相关性肺炎和艰难梭菌感染的发生率分别为 1.0 例/1000 呼吸机日和 0.2 例/1000 患者日，均较低。医院全因死亡率为 2.0%。实现了每位患者住院费用节省 121 美元。
在该人群中，应激性胃病很少见。一旦能够耐受肠内营养，有应激性胃病风险的外科和创伤患者就不需要继续使用药物预防。可以安全地停止对这类患者人群使用药物预防。需要进一步调查以确定在达到肠内喂养目标后继续预防是否有害。
