Prevention of gastrointestinal bleeding in critically ill patients: BMJ Guideline
Gastric acid suppression with proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) is commonly done to prevent gastrointestinal bleeding in critically ill patients. Existing guidelines vary in their recommendations of which population to treat and which agent to use.
The present guideline, published in the BMJ journal, defines the role of gastrointestinal bleeding prophylaxis (stress ulcer prophylaxis) in critically ill patients. The guideline was based on a linked systematic review and network meta-analysis that determined the relative impact of PPIs, H2RAs, sucralfate, or no gastrointestinal bleeding prophylaxis (or stress ulcer prophylaxis) on outcomes important to patients. The review included 12 660 critically ill patients from 72 trials.
According to the review, both PPIs and H2RAs reduced the risk of clinically important bleeding. The effect is larger in patients at higher bleeding risk (those with a coagulopathy, chronic liver disease, or receiving mechanical ventilation but not enteral nutrition or two or more of mechanical ventilation with enteral nutrition, acute kidney injury, sepsis, and shock). PPIs and H2RAs might increase the risk of pneumonia. They probably do not have an effect on mortality, length of hospital stay, or any other important outcomes. PPIs probably reduce the risk of bleeding more than H2RAs.
A guideline panel including patients, clinicians, and methodologists produced these recommendations using standards for trustworthy guidelines and the GRADE approach.
Key Recommendations of the guideline include:
- The use of acid suppression prophylaxis is recommended for people with a higher risk of gastrointestinal bleeding (4% or higher.
- Proton pump inhibitor is suggested in critically ill patients who are going to receive prophylaxis against gastrointestinal bleeding. A histamine-2 receptor antagonist is also a reasonable choice. Also, the use of sucralfate is not recommended.
"In most critically ill patients, the reduction in clinically important gastrointestinal bleeding from gastric acid suppressants is closely balanced with the possibility of pneumonia. Clinicians should consider individual patient values, risk of bleeding, and other factors such as medication availability when deciding whether to use gastrointestinal bleeding prophylaxis," explained the authors.