Should ICU patients get GI prophylaxis? Dr Aaron Holley explores the data tangle, risk tradeoffs, and why he’s still sticking with PPIs — despite the noise.
occur means creating intervention side-effect risk that’s otherwise absent. Large patient numbers must be subjected to that side-effect risk to obtain net benefit. Last, your bedside modeling must be tight, and in medicine it never is.
The story of gastrointestinal prophylaxis in ICU highlights these challenges. It is best told by Deborah Cook, the godmother of ICU research. It’s told through her work. She’s randomized more patients than a sequence generator. Her name is the most critical MeSH term for your systematic review. If Churg, Strauss, and Wegener hadn’t ruined the disease eponym practice, she’d have several to her name. Just as well; we’re all transgressing some currently unidentified but soon-to-be-coined "-ism." Cook’s work has dominated the GI prophylaxis space since the early 1990s. If you’re new to it, start with herfrom 2018. It was published on the heels of the latest randomized control trial on GI prophylaxis in the ICU. Theprovided a tepid endorsement of continued prophylaxis with proton pump inhibitors , but only for those at high risk for bleeding. ) found a mortality signal with PPIs, but in the wrong direction. This drove some back to H2 blockers even though they are less effective than PPI for preventing bleeding. Where I practice I see an equal number of ICU patients on PPI or H2 blockers. There seems to be no clear preference or consensus. . I held on after PEPTIC and SUP-ICU created doubt, and REVISE seemed to vindicate my practice. REVISE found that PPI decreased bleeding without increasing mortality. PPI didn’t increase pneumonia orUnfortunately, it’s never that simple. The mortality signal was still present in the updated systematic review. The mortality "noise" is dependent on severity of illness. It’s the sicker patients who have a higher mortality when given PPI for prophylaxis. Why? I’m not sure. The pneumonia andassociations were absent in SUP-ICU, REVISE, and the updated systematic review. The systematic review authors list multiple possible explanations, given that PPI are associated with an altered microbiome, endothelial changes, and. If there is a causal mechanism affecting mortality, it’s not clear why the direction is discordant across levels of illness severity., the idea was that PPIs were most beneficial in those who are “seriously ill with a high risk of complications.” Fast-forward and the REVISE. Can a patient be at high bleeding risk but have an APACHE II score less than 25? I’m sure they can, but that needle won’t be easy to thread at the bedside.on GI bleeding in the ICU. The focus was on bleeding events that are considered important by ICU survivors and family members. This was a preplanned analysis of data from the REVISE trial. PPI shined again, reducing patient-important events regardless of illness severity. They used a proportional hazards model, that accounts for the competing risk for death, to analyze their primary outcome. Not sure if this provides clarity per se but it does make me feel better about continuing to use prophylactic PPI for my mechanically ventilated patients. Aaron B. Holley, MD, is a professor of medicine at Uniformed Services University in Bethesda, Maryland, and a pulmonary, sleep, and critical care medicine physician at MedStar Washington Hospital Center in Washington, DC. He covers a Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our
Proton Pump Inhibitor Proton-Pump Inhibitor Acid Suppressive Therapy PPI Prophylaxis Patient Safety Pneumonia Microbiome Microbiota Fellowship Fellows Residency Residents APACHE Acute Physiology And Chronic Health Evaluation Washington DC Washington - District Of Columbia Adverse Effects Side Effects Hemorrhage Bleeding Sleep Delirium Hospitals Mesh
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