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Stress ulcer prophylaxis for critically ill children: routine use needs to be re-examined
Sohair Sayed Abu El-Ella1, Muhammad Said El-Mekkawy1, Ali Mohamed Selim1
1Departamento de Pediatría, Facultad de Medicina, Universidad de Menufia, Shibin el-Kom, Egypt.
Insights
Stress ulcer prophylaxis (SUP) with omeprazole did not prevent gastrointestinal bleeding in critically ill children. This practice increased central line-associated bloodstream infections (CLABSI), suggesting SUP should be limited to mechanically ventilated patients.
Area of Science:
- Pediatric critical care medicine
- Gastroenterology
- Pharmacology
Background:
- Stress ulcer prophylaxis (SUP) is common in pediatric intensive care units (PICUs) but lacks strong evidence.
- There is a need for randomized controlled trials (RCTs) to evaluate SUP in critically ill children.
Purpose of the Study:
- To assess the effectiveness of omeprazole for stress ulcer prophylaxis in critically ill children.
- To evaluate the impact of omeprazole on gastrointestinal bleeding and nosocomial infections.
Main Methods:
- A randomized, controlled, open-label trial involving 144 pediatric intensive care unit (PICU) patients with a pediatric Sequential Organ Failure Assessment (pSOFA) score < 16.
- Patients were randomized to receive omeprazole for SUP or no SUP.
- Primary outcomes included upper gastrointestinal bleeding and nosocomial infection.
Main Results:
- The overall incidence of gastrointestinal bleeding was 27.1%, with 5.6% being clinically significant. No significant difference in bleeding was observed between the omeprazole and control groups (27.8% vs 26.4%).
- No significant difference in ventilator-associated pneumonia (VAP) incidence. Central line-associated bloodstream infection (CLABSI) was significantly higher in the omeprazole group (30.6% vs 12.5%).
- Mechanical ventilation was an independent predictor of bleeding. No significant differences in mortality, PICU stay, or mechanical ventilation duration.
Conclusions:
- Omeprazole for SUP in PICU patients with mild to moderate organ dysfunction is not effective in preventing gastrointestinal bleeding.
- Omeprazole use was associated with an increased risk of CLABSI.
- SUP should be restricted to mechanically ventilated children in the PICU.
Introduction:
Stress ulcer prophylaxis (SUP) is commonly used in Paediatric Intensive Care Units (PICUs). However, strong evidence for this practice is lacking and there is a dire need for paediatric randomized controlled trials (RCTs). Our aim was to assess the usefulness of SUP with omeprazole in critically ill children.
Patients And Methods:
We conducted a randomized, controlled open-label trial, including 144 children admitted into a PICU with a paediatric Sequential Organ Failure Assessment (pSOFA) score of less than 16. We randomly allocated patients to SUP with omeprazole or no SUP. The primary outcome was development of upper gastrointestinal bleeding or nosocomial infection.
Results:
The incidence of gastrointestinal bleeding was 27.1%, but clinically significant bleeding developed in only 5.6% of patients. We did not find a significant difference in the incidence of bleeding between the prophylaxis and control groups (27.8% vs 26.4%; P = .85). We also did not find a significant difference between the groups in the incidence of ventilator-associated pneumonia (VAP) (9.6% vs 8.3%; P = .77). The incidence of central line-associated bloodstream infection (CLABSI) was higher in the prophylaxis group compared to the control group (30.6% vs 12.5%; P = .014). None of the patients developed Clostridium difficile-associated diarrhoea. We did not find significant differences in mortality, length of PICU stay or duration of mechanical ventilation. Mechanical ventilation was an independent predictor of bleeding (OR, 6.4; 95%CI, 2.73-14.9).
Conclusion:
In PICU patients with mild to moderate organ dysfunction, omeprazole does not seem to be useful for prevention of gastrointestinal bleeding while at the same time increasing the risk of CLABSI. Thus, we recommend restricting SUP to mechanically ventilated children.
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