Prevention of stress-related ulcer bleeding at the intensive care unit: Risks and benefits of stress ulcer prophylaxis.
Prevention of stress-related ulcer bleeding at the intensive care unit: Risks and benefits of stress ulcer prophylaxis.
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DOI：
10.5492/wjccm.v5.i1.57
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发表时间：
2016-02-04
期刊：
影响因子：
--
通讯作者：
Tacke, Frank
中科院分区：
文献类型：
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作者：
Buendgens, Lukas;Koch, Alexander;Tacke, Frank
应激相关性粘膜疾病是重症监护室（ICU）危重患者的典型并发症。它具有临床相关上消化道（GI）出血的风险。因此，在高危患者中，特别是那些机械通气> 48小时和有明显凝血功能障碍的患者，建议进行应激性溃疡预防（STU）。质子泵抑制剂（PPI）和效果较差的组胺2受体拮抗剂（H2 RA）可预防ICU危重患者的GI出血。然而，常规使用药物治疗并不能降低ICU患者的总死亡率。此外，最近的研究表明，ICU中的腹泻可能与潜在的危害有关，例如感染性并发症的风险增加，特别是医院获得性肺炎和艰难梭菌相关性腹泻。此外，特殊人群，如肝硬化患者，如果接受PPI治疗，死亡率甚至可能增加。同样，PPI可能对肝脏和骨髓都有毒性，一些PPI显示出与其他重要药物（如氯吡格雷）的临床相关相互作用。因此，必须仔细选择所选药物、个体患者风险和获益的特定平衡以及PPI的可能剂量。PPI预防的替代方案包括H2 RA和/或硫糖铝。而不是常规的药物治疗，进一步的试验应该调查风险调整算法，平衡ICU中药物治疗的益处和威胁。
Stress-related mucosal disease is a typical complication of critically ill patients in the intensive care unit (ICU). It poses a risk of clinically relevant upper gastrointestinal (GI) bleeding. Therefore, stress ulcer prophylaxis (SUP) is recommended in high-risk patients, especially those mechanically ventilated > 48 h and those with a manifest coagulopathy. Proton pump inhibitors (PPI) and, less effectively, histamine 2 receptor antagonists (H2RA) prevent GI bleeding in critically ill patients in the ICU. However, the routine use of pharmacological SUP does not reduce overall mortality in ICU patients. Moreover, recent studies revealed that SUP in the ICU might be associated with potential harm such as an increased risk of infectious complications, especially nosocomial pneumonia and Clostridium difficile-associated diarrhea. Additionally, special populations such as patients with liver cirrhosis may even have an increased mortality rate if treated with PPI. Likewise, PPI can be toxic for both the liver and the bone marrow, and some PPI show clinically relevant interactions with important other drugs like clopidogrel. Therefore, the agent of choice, the specific balance of risks and benefits for individual patients as well as the possible dose of PPI has to be chosen carefully. Alternatives to PPI prophylaxis include H2RA and/or sucralfate. Instead of routine SUP, further trials should investigate risk-adjusted algorithms, balancing benefits and threats of SUP medication in the ICU.