Sun Jiayan, Wang Bingxia, Cao Peng, Zhu Hua, Lu Kangsheng, Geng Ping, Tan Dingyu
Department of Pharmacy, Northern Jiangsu People's Hospital, Clinical Medical College, Yangzhou University, Yangzhou 225001, Jiangsu, China.
Department of Emergency, Northern Jiangsu People's Hospital, Clinical Medical College, Yangzhou University, Yangzhou 225001, Jiangsu, China. Corresponding author: Tan Dingyu, Email:
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2019 May;31(5):539-544. doi: 10.3760/cma.j.issn.2095-4352.2019.05.004.
To investigate the benefits and risks of stress ulcer prevention (SUP) using proton pump inhibitors (PPI) for critical patients.
The clinical data of adult critically ill patients admitted to the intensive care unit (ICU) of Northern Jiangsu People's Hospital from January 2016 to December 2018 were retrospectively analyzed. All patients who were treated with PPI for SUP within the first 48 hours after ICU admission were enrolled in the SUP group. Those who not received PPI were enrolled in the control group. A one-to-one propensity score matching (PSM) was performed to control for potential biases. The gender, age, underlying diseases, main diagnosis of ICU, drug use before ICU admission, sequential organ failure score (SOFA) at ICU admission, risk factors of stress ulcer (SU) and PPI usage were recorded. The end point was the incidence of gastrointestinal bleeding, hospital acquired pneumonia, Clostridium difficile infection and 30-day mortality. Kaplan-Meier survival curves were plotted, and survival analysis was performed using the log-rank test.
1 972 critical patients (788 in the SUP group and 1 184 in the control group) were enrolled, and each group enrolled 358 patients after PSM. Prior to PSM, compared with the control group, the SUP group had older patients, more underlying diseases, higher proportion of acute coronary syndrome (ACS), acute cerebrovascular disease, acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and poisoning in main diagnosis of ICU, more serious illness, and more risk factors of SU, indicating that ICU physicians were more likely to prescribe SUP for these patients. The incidence of gastrointestinal bleeding in the SUP group was significantly lower than that in the control group [1.8% (14/788) vs. 3.7% (44/1 184), P < 0.05], while the incidence of hospital acquired pneumonia and 30-day mortality were significantly higher than those in the control group [6.6% (52/788) vs. 3.5% (42/1 184), 17.9% (141/788) vs. 13.1% (155/1 184), both P < 0.01]. There was no significant difference in the incidence of Clostridium difficile infection between the SUP group and the control group [2.9% (23/788) vs. 1.8% (21/1 184), P > 0.05]. After the propensity scores for age, underlying diseases, severity of illness and SU risk factors were matched, there was no significant difference in the incidence of gastrointestinal bleeding or 30-day mortality between the SUP group and the control group [2.2% (8/358) vs. 3.4% (12/358), 15.9% (57/358) vs. 13.7% (49/358), both P > 0.05], but the incidence of hospital acquired pneumonia in the SUP group was still significantly higher than that in the control group [6.7% (24/358) vs. 3.1% (11/358), P < 0.05]. Kaplan-Meier survival curve analysis showed that the 30-day cumulative survival rate of the SUP group was significantly lower than that of the control group before the PSM (log-rank test: χ = 9.224, P = 0.002). There was no significant difference in the 30-day cumulative survival rate between the two groups after PSM (log-rank test: χ = 0.773, P = 0.379).
For critical patients, the use of PPI for SUP could not significantly reduce the incidence of gastrointestinal bleeding and mortality, but increase the risk of hospital acquired pneumonia.
探讨使用质子泵抑制剂（PPI）对重症患者进行应激性溃疡预防（SUP）的益处和风险。
回顾性分析2016年1月至2018年12月在苏北人民医院重症监护病房（ICU）收治的成年重症患者的临床资料。所有在ICU入院后48小时内接受PPI进行SUP治疗的患者纳入SUP组。未接受PPI治疗的患者纳入对照组。进行一对一倾向评分匹配（PSM）以控制潜在偏倚。记录性别、年龄、基础疾病、ICU主要诊断、ICU入院前用药情况、ICU入院时序贯器官衰竭评分（SOFA）、应激性溃疡（SU）危险因素及PPI使用情况。终点指标为胃肠道出血、医院获得性肺炎、艰难梭菌感染的发生率及30天死亡率。绘制Kaplan-Meier生存曲线，并采用对数秩检验进行生存分析。
共纳入1972例重症患者（SUP组788例，对照组1184例），PSM后每组纳入358例患者。PSM前，与对照组相比，SUP组患者年龄更大（P<0.05），基础疾病更多，ICU主要诊断中急性冠状动脉综合征（ACS）、急性脑血管病、慢性阻塞性肺疾病急性加重（AECOPD）及中毒的比例更高，病情更严重，SU危险因素更多，提示ICU医生更倾向于为这些患者开具SUP。SUP组胃肠道出血发生率显著低于对照组[1.8%（14/788） vs. 3.7%（44/1184），P<0.05]，而医院获得性肺炎发生率及30天死亡率显著高于对照组[6.6%（52/788） vs. 3.5%（42/1184），17.9%（141/788） vs. 13.1%（155/1184），均P<0.01]。SUP组与对照组艰难梭菌感染发生率差异无统计学意义[2.9%（23/788） vs. 1.8%（21/1184），P>0.05]。对年龄、基础疾病、病情严重程度及SU危险因素的倾向评分进行匹配后，SUP组与对照组胃肠道出血发生率及30天死亡率差异无统计学意义[2.2%（8/358） vs. 3.4%（12/358），15.9%（57/358） vs. 13.7%（49/358），均P>0.05]，但SUP组医院获得性肺炎发生率仍显著高于对照组[6.7%（24/358） vs. 3.1%（11/358），P<0.05]。Kaplan-Meier生存曲线分析显示，PSM前SUP组30天累积生存率显著低于对照组（对数秩检验：χ=9.224，P=0.002）。PSM后两组30天累积生存率差异无统计学意义（对数秩检验：χ=0.773，P=0.379）。
对于重症患者，使用PPI进行SUP不能显著降低胃肠道出血发生率及死亡率，但会增加医院获得性肺炎的风险。
