应激性溃疡预防停药指导对机械通气重症患者的影响：一项前后队列研究
Impact of Stress Ulcer Prophylaxis Discontinuation Guidance in Mechanically Ventilated, Critically Ill Patients: A Pre-Post Cohort Study.
作者信息
Jones Christopher A, Betthauser Kevin D, Lizza Bryan D, Juang Paul A, Micek Scott T, Kollef Marin H
机构信息
Washington University School of Medicine, Saint Louis, MO, USA.
Barnes-Jewish Hospital, Saint Louis, MO, USA.
出版信息
Hosp Pharm. 2022 Aug;57(4):510-517. doi: 10.1177/00185787211061371. Epub 2021 Dec 7.
PURPOSE
Recent data highlight unclear efficacy and potential negative sequelae of stress ulcer prophylaxis (SUP) in the intensive care unit (ICU). Minimizing SUP exposure has pertinent clinical and other implications. This study assessed medication use and clinical outcomes before and after implementation of a practice guideline promoting early discontinuation of SUP in mechanically ventilated ICU patients.
METHODS
Retrospective, single-center, pre-post cohort study within a medical ICU at a large, academic medical center. Adult patients requiring mechanical ventilation and receiving SUP via a histamine-2 receptor antagonist (H2RA) or proton pump inhibitor (PPI) were eligible for inclusion. The clinical practice guideline was implemented on January 1, 2020. The impact of implementation was assessed via percent of patient-days with inappropriate SUP. Incidence of clinically important GI bleed was the primary safety outcome.
RESULTS
A total of 137 pre-guideline and 112 post-guideline patients were included. Comorbidity burden was similar between groups. A higher prevalence of baseline vasopressor receipt (39% vs 67%, < .01) and acute kidney injury (56% vs 69%, = .04) was observed in post-guideline patients. Post-guideline patients experienced a significantly lower percentage of patient-days of inappropriate SUP (25% vs 50%, < .01) as well as higher rates of SUP discontinuation before extubation (71% vs 12%, < .01) and during ICU stay (93% vs 50%, < .01). Post-guideline patients observed a significantly lower incidence of SUP at hospital discharge (4% vs 35%, < .01). No differences in bleeding outcomes were observed, though post-guideline patients experienced longer durations of mechanical ventilation, ICU stay, and hospital stay.
CONCLUSIONS
Implementation of an early SUP discontinuation guideline was associated with significant improvements in SUP prescribing practices. Baseline differences between groups likely explain observed differences in clinical outcomes.
目的
近期数据凸显了重症监护病房（ICU）应激性溃疡预防（SUP）的疗效不明确以及潜在的不良后遗症。尽量减少SUP的使用具有相关的临床及其他意义。本研究评估了在实施一项促进机械通气的ICU患者早期停用SUP的实践指南前后的药物使用情况及临床结局。
方法
在一家大型学术医疗中心的内科ICU内进行回顾性、单中心、前后队列研究。需要机械通气并通过组胺-2受体拮抗剂（H2RA）或质子泵抑制剂（PPI）接受SUP的成年患者符合纳入标准。临床实践指南于2020年1月1日实施。通过不适当SUP的患者日百分比评估实施的影响。临床重要胃肠道出血的发生率是主要的安全性结局。
结果
共纳入137例指南实施前患者和112例指南实施后患者。两组之间的合并症负担相似。指南实施后患者中基线血管升压药使用情况（39%对67%，P<0.01）和急性肾损伤（56%对69%，P=0.04）的患病率更高。指南实施后患者的不适当SUP患者日百分比显著降低（25%对50%，P<0.01），以及拔管前（71%对12%，P<0.01）和ICU住院期间（93%对50%，P<0.01）SUP停用率更高。指南实施后患者出院时SUP的发生率显著降低（4%对35%，P<0.01）。未观察到出血结局的差异，尽管指南实施后患者的机械通气、ICU住院和住院时间更长。
结论
早期停用SUP指南的实施与SUP处方实践的显著改善相关。组间的基线差异可能解释了观察到的临床结局差异。
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