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Gastric Acid Suppressant Prophylaxis in Pediatric Intensive Care: Current Practice as Reflected in a Large
Andrew T Costarino1, Dingwei Dai, Rui Feng
11Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA. 2Division of Cardiac Critical Care, The Children's Hospital of Philadelphia, Philadelphia, PA. 3Center for Pediatric Clinical Effectiveness and Policy Lab, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA. 4Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. 5Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA. 6Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. 7Division of General Pediatrics, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA.
Insights
Acid suppressant medications, including histamine 2 receptor blockers and proton pump inhibitors, are widely used in pediatric intensive care units (PICUs). However, their prescription patterns vary significantly across different patient conditions and hospitals.
Area of Science:
- Pediatric critical care medicine
- Gastroenterology
- Pharmacology
Background:
- Stress-related gastrointestinal bleeding is a concern in pediatric intensive care units (PICUs).
- Acid suppressant medications, such as histamine 2 receptor blockers (H2RBs) and proton pump inhibitors (PPIs), are standard treatments to increase gastric pH.
- Understanding the utilization of these medications in PICU patients is crucial for optimizing care.
Purpose of the Study:
- To describe the use of H2RBs and PPIs in a national sample of PICU patients.
- To identify factors associated with the prescription of these acid suppressant medications.
- To analyze trends in H2RB and PPI use over time.
Main Methods:
- Retrospective cohort analysis of a large administrative database (Pediatric Health Information System).
- Inclusion of hospitalizations for patients aged 20 years or younger admitted to a PICU across 42 US children's hospitals (2007-2011).
- Assessment of demographics, diagnoses, procedures, and medication use (H2RB, PPI, or both) on admission.
Main Results:
- Acid suppressant use (H2RB or PPI) was observed in 60% of hospitalizations, with H2RBs being more common than PPIs.
- Medication use increased from 2007 to 2011.
- Gastrointestinal bleeding occurred in 1.32% of hospitalizations; sepsis, coagulopathy, and mechanical ventilation were associated with higher acid suppressant use.
- Significant variation in medication use was noted across hospitals (28%-87%) and patient conditions.
Conclusions:
- H2RBs and PPIs are frequently prescribed in PICU patients, but their use shows considerable variation.
- Institutional preferences appear to influence prescribing patterns.
- Gastrointestinal hemorrhage is relatively infrequent in this patient population.
- The study's limitations preclude examining the association between medication use and patient outcomes.
Objectives:
Stress-related gastrointestinal bleeding may occur in PICU patients. Raising gastric pH with acid suppressant medications is the accepted treatment. We describe the use of histamine 2 receptor blockers and proton pump inhibitors and associated factors among a national sample of PICU patients.
Design:
Retrospective cohort analysis using Pediatric Health Information System clinically detailed administrative database.
Setting:
Forty-two children's hospitals throughout the United States.
Patients:
All hospitalizations for all patients 20 years old or younger, admitted directly to a PICU, from January 1, 2007, through December 31, 2011.
Interventions:
None.
Measurements And Main Results:
The exposure of interest was treatment with a histamine 2 receptor blocker, proton pump inhibitor, or both on the first day of PICU admission. Demographics, principal and additional diagnoses, and procedure codes were assessed. For each hospitalization, principal diagnosis, coagulation disorder, head trauma, spinal trauma, severe burns, sepsis, gastrointestinal hemorrhage, mechanical ventilation, blood product transfusion, and 10 complex chronic conditions were identified. The frequency of principal diagnoses was determined to identify the most prevalent PICU diseases. Acid suppressant use was categorized as high or low. Three hundred and thirty-six thousand ten inpatient hospitalizations were sampled. Histamine 2 receptor blocker or proton pump inhibitor was used in 60.0%, with histamine 2 receptor blocker alone in 70.4%, proton pump inhibitor alone in 17.8%, and both agents in 11.8%. Use increased over the sample years 2007 through 2011. Gastrointestinal bleeding occurred in 1.32% of hospitalizations with transfusion needed in 0.1%. Among most prevalent diagnoses, histamine 2 receptor blocker and proton pump inhibitor use ranged from 33% to 87%. Sepsis, coagulopathy, and mechanical ventilation identified higher use. Use of histamine 2 receptor blocker or proton pump inhibitor among hospitals varied considerably ranging from 28% to 87%.
Conclusions:
Histamine 2 receptor blocker and proton pump inhibitor are prescribed in most PICU patients, but significant variation exists across health conditions and hospitals. Institutional preferences likely influence variation. Gastrointestinal hemorrhage is infrequent in the current era. Study data limitations prevent examination of associations between medication use and patient outcomes.
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