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Toews I, Hussain S, Nyirenda JLZ, Willis MA, Kantorová L, Slezáková S, Boltena MT, Peter JV, Fontes LES, Klugar M, Sadeghirad B, Meerpohl JJ. Pharmacological interventions for preventing upper gastrointestinal bleeding in people admitted to intensive care units: a network meta-analysis. BMJ Evid Based Med 2024:bmjebm-2024-112886. [PMID: 38997152 DOI: 10.1136/bmjebm-2024-112886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2024] [Indexed: 07/14/2024]
Abstract
OBJECTIVES To assess the efficacy and safety of pharmacological interventions for preventing upper gastrointestinal (GI) bleeding in people admitted to intensive care units (ICUs). DESIGN AND SETTING Systematic review and frequentist network meta-analysis using standard methodological procedures as recommended by Cochrane for screening of records, data extraction and analysis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence. PARTICIPANTS Randomised controlled trials involving patients admitted to ICUs for longer than 24 hours were included. SEARCH METHODS The Cochrane Gut Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Latin American and Caribbean Health Science Information database (LILACS) databases were searched from August 2017 to March 2022. The search in MEDLINE was updated in April 2023. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). MAIN OUTCOME MEASURES The primary outcome was the prevention of clinically important upper GI bleeding. RESULTS We included 123 studies with 46 996 participants. Cimetidine (relative risk (RR) 0.56, 95% CI 0.40 to 0.77, moderate certainty), ranitidine (RR 0.54, 95% CI 0.38 to 0.76, moderate certainty), antacids (RR 0.48, 95% CI 0.33 to 0.68, moderate certainty), sucralfate (RR 0.54, 95% CI 0.39 to 0.75, moderate certainty) and a combination of ranitidine and antacids (RR 0.13, 95% CI 0.03 to 0.62, moderate certainty) are likely effective in preventing upper GI bleeding.The effect of any intervention on the prevention of nosocomial pneumonia, all-cause mortality in the ICU or the hospital, duration of the stay in the ICU, duration of intubation and (serious) adverse events remains unclear. CONCLUSIONS Several interventions seem effective in preventing clinically important upper GI bleeding while there is limited evidence for other outcomes. Patient-relevant benefits and harms need to be assessed under consideration of the patients' underlying conditions.
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Affiliation(s)
- Ingrid Toews
- Institute for Evidence in Medicine, Medical Center - Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Salman Hussain
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - John L Z Nyirenda
- Institute for Evidence in Medicine, Medical Center - Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Maria A Willis
- Department of General, Visceral, Thorax and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Lucia Kantorová
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Simona Slezáková
- Cochrane Czech Republic, Czech Republic: a JBI Centre of Excellence, Czech GRADE Network, Institute of Health Information and Statistics of the Czech Republic, Prague, Czech Republic
| | - Minyahil Tadesse Boltena
- Ethiopian Evidence Based Health Care Center, Institute of Health, A Joanna Briggs Institute's Center of Excellence, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - John Victor Peter
- Medical Intensive Care Unit, Christian Medical College & Hospital, Vellore, India
| | | | - Miloslav Klugar
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Center of Evidence-Based Education and Arts Therapies: A JBI Affiliated Group, Palacky University Olomouc Faculty of Education, Olomouc, Olomoucký, Czech Republic
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine, Medical Center - Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
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Yao Y, Ba T, Bao B, Zhang S, Kong L. Sepsis as a Potential Risk Factor for Upper Gastrointestinal Bleeding in Critically Ill Patients: A Systematic Review and Meta-analysis. J Intensive Care Med 2024:8850666241252048. [PMID: 38813775 DOI: 10.1177/08850666241252048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Purpose: Sepsis is a common and critical condition in intensive care units (ICUs) known to complicate patient outcomes. Previous studies have indicated an association between sepsis and various ICU morbidities, including upper gastrointestinal bleeding (UGIB). However, the extent of this relationship and its implications in ICU settings remain inadequately quantified. This study aims to elucidate the association between sepsis and the risk of UGIB in ICU patients. Methods: A comprehensive meta-analysis was conducted, encompassing nine studies with a total of nearly 9000 participants. These studies reported events for both sepsis and nonsepsis patients separately. Pooled odds ratios (ORs) were calculated to assess the risk of UGIB in septic versus nonseptic ICU patients. Subgroup analyses were conducted based on age and study design, and both unadjusted and adjusted ORs were examined. Results: The pooled OR indicated a significant association between sepsis and UGIB (OR = 3.276, 95% CI: 1.931 to 5.557). Moderate heterogeneity was observed (I² = 43.9%). The association was significant in adults (pooled OR = 4.083) but not in children. No difference in association was found based on the study design. Unadjusted and adjusted ORs differed slightly, indicating the influence of confounding factors. Conclusion: This meta-analysis reveals a significant association between sepsis and an increased risk of UGIB in ICU patients, particularly in adults. These findings highlight the need for vigilant monitoring and proactive management of septic ICU patients to mitigate the risk of UGIB. Future research should focus on understanding the underlying mechanisms and developing tailored preventive strategies.
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Affiliation(s)
- Yanfen Yao
- Department of Intensive Care Medicine, Shandong Provincial Third Hospital, Shandong University, Jinan, China
- The First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Tejin Ba
- Department of Emergency, International Mongolian Hospital of Inner Mongolia, Hohhot, China
| | - Bagenna Bao
- Department of Emergency, International Mongolian Hospital of Inner Mongolia, Hohhot, China
| | - Shuanglin Zhang
- Department of Emergency, International Mongolian Hospital of Inner Mongolia, Hohhot, China
| | - Li Kong
- The First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
- Department of Emergency Center, Shandong University of Traditional Chinese Medicine Affiliated Hospital, Jinan, China
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Proton Pump Inhibitor Use and Associated Infectious Complications in the PICU: Propensity Score Matching Analysis. Pediatr Crit Care Med 2022; 23:e590-e594. [PMID: 35994620 DOI: 10.1097/pcc.0000000000003063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES We aimed to evaluate the association between proton pump inhibitor (PPI) exposure and nosocomial infection (NI) during PICU stay. DESIGN Propensity score matched analysis of a single-center retrospective cohort from January 1, 2017, to December 31, 2018. SETTING Tertiary medical and surgical PICU in France. PATIENTS Patients younger than 18 years old, admitted to the PICU with a stay greater than 48 hours. INTERVENTION Patients were retrospectively allocated into two groups and compared depending on whether they received a PPI or not. MEASUREMENTS AND MAIN RESULTS Seven-hundred fifty-four patients were included of which 231 received a PPI (31%). PPIs were mostly used for stress ulcer prophylaxis (174/231; 75%), but upper gastrointestinal bleed risk factors were rarely present (18%). In the unadjusted analyses, the rate of NI was 8% in the PPI exposed group versus 2% in the nonexposed group. After propensity score matching ( n = 184 per group), we failed to identify an association between PPI exposure and greater odds of NI (adjusted odds ratio 2.9 [95% CI, 0.9-9.3]; p = 0.082). However, these data have not excluded the possibility that there is up to nine-fold greater odds of NI. CONCLUSIONS This study highlights the prevalent use of PPIs in the PICU, and the potential association between PPIs and nine-fold greater odds of NI is not excluded.
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Ni X, Lin M, Li J, Zeng L, Li W, Huang L, Li D, Zhang L. Development of an evaluation indicator system for the rational use of proton pump inhibitors in pediatric intensive care units: An application of Delphi method. Medicine (Baltimore) 2021; 100:e26327. [PMID: 34128875 PMCID: PMC8213291 DOI: 10.1097/md.0000000000026327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/25/2021] [Indexed: 01/04/2023] Open
Abstract
Proton pump inhibitors are frequently used to prevent gastrointestinal bleeding in critically ill patients. But there is little information in the instructions about the usages for children. It is important to monitor the appropriate use of proton pump inhibitors, especially in pediatrics. Therefore, we developed an evaluation indicator system for the rational use of proton pump inhibitors in pediatric intensive care units.First, a systematic review was conducted to developed the initial indicators. Then 2 rounds of Delphi surveys were conducted to collecting opinions from a panel of independent experts, and the indicator system was modified to form the final indicators according to the opinions. Finally, the analytic hierarchy procedure was used to determine the weight of each indicator.A total of 6 guidelines and 2 studies met the inclusion and exclusion criteria. Based on literature and discussion among experts, an initial indicator system including 4 first-rank indicators and 12 second-rank indicators was formed. After 2 rounds of Delphi surveys, 2 indicators were added, 5 indicators were deleted, and 1 indicator was revised, so the final indicator system contained a total of 13 indicators including 3 first-rank indicators (drug selection, drug usage and dosage, duration of drug therapy) and 10 second-rank indicators (the proportion of PPIs used in children, children under 1 year old, children who is using glucocorticoids, children with nonsteroidal anti-inflammatory drugs, children with gastroesophageal reflux disease, children with sepsis, children with ventilators in PICU; the strength of PPIs' use, the proportion of omeprazole in children using PPIs during the same period; the average days of PPIs used in children). By analyzing scores, all coefficients met the standard, indicating the indicators were scientific and credible.Through a two-round Delphi survey, 3 first-rank indicators and ten second-rank indicators were developed, which will help drug administrative departments to promote the rational use of PPIs for children in PICUs. What is more, our study can constitute a methodological reference for the development of other indicator systems.
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Affiliation(s)
- Xiaofeng Ni
- Department of Pharmacy
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education (Sichuan University)
- West China School of Medicine, Sichuan University
| | - Mao Lin
- Department of Pharmacy
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education (Sichuan University)
- West China School of Pharmacy, Sichuan University
| | - Jialian Li
- Department of Pharmacy
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education (Sichuan University)
- West China School of Pharmacy, Sichuan University
| | - Linan Zeng
- Department of Pharmacy
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education (Sichuan University)
| | - Wenrui Li
- Department of Pharmacy
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education (Sichuan University)
- West China School of Pharmacy, Sichuan University
| | - Liang Huang
- Department of Pharmacy
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education (Sichuan University)
| | - Deyuan Li
- Pediatric intensive care, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Lingli Zhang
- Department of Pharmacy
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education (Sichuan University)
- West China School of Pharmacy, Sichuan University
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