Stress Ulcer Prophylaxis in Critically Ill Children: A Multicenter Observational Study
Mark Duffett1,2, Alice Chan3, Jordan Closs1
1Department of Pharmacy, McMaster Children's Hospital, Hamilton, ON, Canada.
Insights
Stress ulcer prophylaxis is common in Canadian pediatric intensive care units (PICUs), but its routine use warrants examination. Clinically significant gastrointestinal bleeding is rare in these patients.
Area of Science:
- Pediatric Critical Care Medicine
- Pharmacology
- Gastroenterology
Background:
- Stress ulcer prophylaxis (SUP) is frequently administered to critically ill children.
- Current practices in Canadian pediatric intensive care units (PICUs) for SUP are not well-described.
Purpose of the Study:
- To describe the current practices of stress ulcer prophylaxis in Canadian PICUs.
- To identify factors associated with the use of SUP in mechanically ventilated children.
Main Methods:
- A multicenter cohort study was conducted across seven Canadian PICUs.
- Defined SUP as the use of proton-pump inhibitors, histamine-2 receptor antagonists, or sucralfate within the first two PICU days.
- Included 378 children requiring mechanical ventilation; analyzed data on medication use, patient characteristics, and outcomes.
Main Results:
- Seventy percent of all children received acid suppression during their PICU stay.
- 54% of eligible children received SUP, with histamine-2 receptor antagonists being the most common class.
- Older age, higher Pediatric Risk of Mortality III score, use of NSAIDs/corticosteroids, and invasive mechanical ventilation were associated with increased SUP use; enteral nutrition was associated with decreased use.
- Clinically important gastrointestinal bleeding occurred in 0.8% of children; C. difficile-associated diarrhea in 1%.
Conclusions:
- Stress ulcer prophylaxis is widely used in Canadian PICUs.
- The low incidence of clinically important gastrointestinal bleeding suggests that the utility of routine SUP should be critically evaluated.
- Further research is needed to optimize SUP strategies in pediatric critical care.
Objective:
To describe current stress ulcer prophylaxis practice in Canadian PICUs.
Design:
Multicenter cohort study. We defined stress ulcer prophylaxis as the use of a proton-pump inhibitor, histamine-2 receptor antagonist, or sucralfate within the first 2 PICU days among children who had not been on these medications at home and had no evidence of gastrointestinal bleeding.
Setting:
Seven PICUs in Canada.
Patients:
Three hundred seventy-eight children requiring mechanical ventilation.
Interventions:
None.
Measurements And Main Results:
Children were ventilated for a median (interquartile range) of 2 days (1-6 d) and stayed in the PICU for a median (interquartile range) of 4 days (2-10 d). The median (interquartile range) age was 1.3 years (0.3-6.7 yr). Seventy percent of all children received acid suppression during their PICU stay. One hundred sixty-seven (54%) of the 309 children eligible for stress ulcer prophylaxis received it. Histamine-2 receptor antagonists were the most frequently used class (66%), followed by proton-pump inhibitors (47%) and sucralfate (4%), and 20% received more than one class. Stress ulcer prophylaxis was continued on the PICU transfer orders for 34% of these children. Children who received prophylaxis were older and had a higher Pediatric Risk of Mortality III score, more often received nonsteroidal anti-inflammatory drugs and systemic corticosteroids and received less enteral nutrition. In multivariate analysis, age and invasive mechanical ventilation were independently associated with an increased likelihood of receiving stress ulcer prophylaxis and receiving feeds was independently associated with a decreased likelihood of receiving stress ulcer prophylaxis. Gastrointestinal bleeding was reported in 21 (6%) of 378 children; three (0.8%) were clinically important. Eighteen percent were treated for a new respiratory tract infection, and 1% developed Clostridium difficile-associated diarrhea.
Conclusions:
Stress ulcer prophylaxis is common in Canadian PICUs. Clinically important gastrointestinal bleeding and C. difficile-associated diarrhea are rare, and the utility of routine prophylaxis should be examined.
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