We believe that the ICU-patients, especially ventilated patients, are prone to having stress ulcers and one of the components of the daily ICU drill is to ensure that the patient is on ulcer prophylactics.
We do this despite how the incidence of stress-induced GI-bleeding has been steadily decreasing, possibly due to earlyer initiation of enteral feeding. We do this despite how studies have reported associations between proton pump inhibitors and ventilator-associated pneumonias and c. difficile infections. Therefore, as per our current guidelines, virtually all intubated ICU-patients are on proton pump inhibitors. A paper in Crit Care Med, however, could find no evidence of that actually benefiting patients.
The authors designed a double-blind prospective single-centre study where the patients received either once-daily 40 mg IV Pantoprazole or the equal volume saline placebo. The interventions went on as long as the patients were ventilated or for a maximum of 14 days. The study included 104 vs. 105 patients who had mechanical invasive ventilation for longer than 24h and who would receive enteral nutrition within 48h of admission.
The primary outcomes were significant GI bleeding, ventilator-associated infections and Clostridium Difficile infections. GI bleeding was defined a overt bleeding accompanied by a drop in PAO of 20 mmHg , a drop in hemoglobin of 20 g/L or more within 24h or the patient needing endoscopy or surgery for hemostasis.
The authors found no episodes of clinically significant bleeding in either group. There was no difference in ventilator-associated complications or infections (n=1 vs 2). Only one patient (on pantoprazole) was diagnosed with clostridium difficile. There was no significant in secondary outcomes such as daily hemoglobin concentrations or 90-day mortality.
The authors conclude that they saw no evidence of pantoprazole prophylaxis having beneficial or harmful effects. The authors acknowledge that this is a small study.
Study lives here:
Crit Care Med. 2016 Oct;44(10):1842-50. Pantoprazole or Placebo for Stress Ulcer Prophylaxis (POP-UP): Randomized Double-Blind Exploratory Study. Selvanderan SP1, Summers MJ, Finnis ME, Plummer MP, Ali Abdelhamid Y, Anderson MB, Chapman MJ, Rayner CK, Deane AM.