Maier R V, Mitchell D, Gentilello L
Department of Surgery, Harborview Medical Center, University of Washington, Seattle.
Ann Surg. 1994 Sep;220(3):353-60; discussion 360-3. doi: 10.1097/00000658-199409000-00011.
The authors compared the results of sucralfate versus H2 blocker +/- antacid as prophylaxis for stress ulceration in an intensive care unit patient population.
Stress ulceration carries high morbidity and mortality for the patient who is critically ill. Gastric acid neutralization is an effective prophylaxis. The impact of increased gastric colonization with bacterial pathogens on nosocomial pneumonia after acid neutralization is unclear. The efficacy of sucralfate prophylaxis for stress ulceration and its the effect on the nosocomial pneumonia rate is controversial. The financial implications of sucralfate prophylaxis versus H2 blocker-based acid neutralization therapy has not been studied.
Ninety-eight injured patients who were critically ill and who required intubation and intensive care unit (ICU) support for at least 72 hours without gastric feeding were randomized and received either maximal H2 blocker infusion therapy (continuous infusion of ranitidine at 0.25 mg/kg/hr after a loading dose of 0.5 mg/kg) plus antacids (for persistent pH < 4) or sucralfate (1 g every 6 hours via nasogastric tube) for stress ulcer prophylaxis. Efficacy in preventing stress ulcer complications was determined. The impact of each therapeutic approach on development of nosocomial pneumonia was evaluated. The charges/cost for each approach was analyzed.
Heme-positive gastric aspirates occurred in 99% of the patients, whereas 12 (7 in the H2 blocker group and 5 in the sucralfate group) were grossly positive for blood. However, only one from each group required transfusion, and one in the H2 blocker group required operation. Gastric colonization preceded tracheobronchial colonization in five patients in the H2 blocker group and one patient in the sucralfate group; simultaneous gastric/oropharyngeal colonization preceded positive tracheobronchial growth in six patients who received H2 blocker and one patient who received sucralfate. The overall pneumonia rate was 27.5% in the H2 blocker group and 20.8% in the sucralfate group (p = 0.48). Days on ventilator were 13.5 versus 9.1, (p = 0.06), ICU lengths of stay were 14.7 versus 10.2 (p = 0.06), and hospital lengths of stay were 27.8 versus 20.0 (p = 0.029) for the H2 blocker group and sucralfate group, respectively. Based on current charges and protocols for optimal H2 blocker and sucralfate prophylaxis, use of sucralfate rather than H2 blockers would decrease the annual cost by more than $30,000 per bed.
Sucralfate is as efficacious as maximal H2 blocker therapy for stress ulceration prophylaxis, and may have a beneficial effect on the incidence of nosocomial pneumonia. Sucralfate has a major reduction on nursing requirements for stress ulcer prophylaxis and would save approximately $30,000 per ICU bed per year in patient charges.
作者比较了硫糖铝与H2受体阻滞剂加/不加抗酸剂用于重症监护病房患者应激性溃疡预防的效果。
应激性溃疡对重症患者具有较高的发病率和死亡率。胃酸中和是一种有效的预防措施。胃酸中和后胃内细菌病原体定植增加对医院获得性肺炎的影响尚不清楚。硫糖铝预防应激性溃疡的疗效及其对医院获得性肺炎发生率的影响存在争议。硫糖铝预防与基于H2受体阻滞剂的胃酸中和疗法的经济影响尚未得到研究。
98例重伤且需插管并在重症监护病房（ICU）支持至少72小时且未进行胃肠内喂养的患者被随机分组，接受最大剂量H2受体阻滞剂输注疗法（负荷剂量0.5mg/kg后以0.25mg/kg/hr持续输注雷尼替丁）加抗酸剂（用于持续pH<4）或硫糖铝（经鼻胃管每6小时1g）预防应激性溃疡。确定预防应激性溃疡并发症的疗效。评估每种治疗方法对医院获得性肺炎发生的影响。分析每种方法的费用。
99%的患者胃抽吸物潜血阳性，而12例（H2受体阻滞剂组7例，硫糖铝组5例）胃内有明显出血。然而，每组仅1例需要输血，H2受体阻滞剂组1例需要手术。H2受体阻滞剂组5例患者和硫糖铝组1例患者胃内定植先于气管支气管定植；接受H2受体阻滞剂的6例患者和接受硫糖铝的1例患者胃/口咽同时定植先于气管支气管阳性生长。H2受体阻滞剂组的总体肺炎发生率为27.5%，硫糖铝组为20.8%（p=0.48）。H2受体阻滞剂组和硫糖铝组的机械通气天数分别为13.5天和9.1天（p=0.06），ICU住院时间分别为14.7天和10.2天（p=0.06），住院时间分别为27.8天和20.0天（p=0.029）。根据目前最佳H2受体阻滞剂和硫糖铝预防的费用和方案，使用硫糖铝而非H2受体阻滞剂将使每张床位每年的费用降低超过30000美元。
硫糖铝在预防应激性溃疡方面与最大剂量H2受体阻滞剂疗法同样有效，并且可能对医院获得性肺炎的发生率有有益影响。硫糖铝可大幅减少应激性溃疡预防的护理需求，并且每年可为每张ICU床位节省约30000美元的患者费用。
