Supportive and Preventive Medicine
Antacids, sucralfate, H2RAs, and PPIs have all reduced clinically significant SRMD-related
bleeding compared with placebo.
Studies evaluating interventions for stress-related bleeding are summarized in Table 5.
Comparison
Study
Design
Population
CIB
Notes
H2RA vs
Sucralfate
N Engl J Med
1998;338:791-7
Multicenter,
randomized,
blinded,
placebo-
controlled
mechanically
ventilated
ICU patients
| • | CIB reduced |
|---|
with H2RA (RR
0.44; 95% CI,
0.21–0.92)
| • | No difference in in |
|---|
mortality or VAP
2017;40:21-30
Meta-analysis,
21 RCTs
3121 ICU
patients
| • | Similar risk of |
|---|
overt or CIB
| • | Conclusions limited |
|---|
by changes in practice
(ventilator bundles,
early nutrition)
H2RA vs PPI
2016;20:120
Meta-analysis,
19 RCTs
2117 ICU
patients
| • | CIB reduced |
|---|
with PPI (RR
0.39; 95% CI,
0.21–0.71;
p=0.002)
| • | No difference in |
|---|
mortality or VAP
| • | Conclusions limited by |
|---|
disproportionate risk
factors between patient
groups, inconsistent
definitions of bleeding,
different routes/dosing
of agents
Intern Med
2014;174:564-74
Retrospective
cohort
35,000
mechanically
ventilated
ICU patients
| • | CIB increased |
|---|
with PPI (OR
2.24; 95% CI,
1.81–2.76)
| • | Conclusions possibly |
|---|
limited by selection
bias
Chest
2018;154:557-66
Retrospective
cohort
49,576 ICU
patients
| • | CIB increased |
|---|
with PPI (HR
2.37; 95% CI,
1.61–3.5)
| • | Conclusions possibly |
|---|
limited by selection
bias
“PEPTIC” trial.
323:616-26
Open-label,
randomized,
cluster
crossover
28,982
mechanically
ventilated
ICU patients
| • | CIB reduced |
|---|
with PPI (RR
0.73; 95% CI,
0.57–0.92)
| • | No difference |
|---|
in mortality
(RR, 1.05; 95%
CI, 1.00–1.10;
p=0.54)
| • | Possible signal of harm |
|---|
with PPI use; increased
mortality with PPI
use in cardiac surgery
population (RR 1.27;
95% CI, 0.51-1.09)
| • | Poor protocol |
|---|
adherence limits
conclusions—only
63.4% in H2RA group
and 82.5% in PPI
group exclusively
received their assigned
therapy