Ebook Critical care update 2017: Part 2
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Ebook Critical care update 2017: Part 2
Acid Suppression in Critically III: Is It Really Necessary?Samir SahuỈ INTRODUCTION____________ _______Gastric mucosa is sensitive to changes in hemod Ebook Critical care update 2017: Part 2dynamics such as hypotension resulting in reduced perfusion and cytokine-mediated inflammation. This results in stress relatcd mucosal disease (SRMĐ), which endoscopically may range from superficial erosions to multiple idcers and can lead to clinically important bleeding episodes requiring blood tr Ebook Critical care update 2017: Part 2ansfusion.1 Prophylaxis of such lesions is nowadays available both as proton pump inhibitors (PPI) and histamine-2 receptor antagonists (H2RA). Both oEbook Critical care update 2017: Part 2
f these agents are well tolerated and are able to decrease incidence of bleeding episode.2 In spite of these pharmacological agents, stress ulcer propAcid Suppression in Critically III: Is It Really Necessary?Samir SahuỈ INTRODUCTION____________ _______Gastric mucosa is sensitive to changes in hemod Ebook Critical care update 2017: Part 2tensivists have expressed concerns about the safety of SUP, especially with respect to infectious complications.g EPIDEMIOLOGY__________Stress-related mucosal disease is present In most critically ill patients, but only' a few patients experience overt bleeding complications. Only around 1% of them Ebook Critical care update 2017: Part 2develop SMRĐ-related gastrointestinal (Gl) bleeding.2,3LfATHOPHYSIOLOGYBoth systemic hypotension due to absolute or relative hypovolemia, cardiogenicEbook Critical care update 2017: Part 2
or obstructive shock, use of vasopressors and local splanchnic hypoperfusion due to positive end expiratory pressure in patients on mechanical ventilaAcid Suppression in Critically III: Is It Really Necessary?Samir SahuỈ INTRODUCTION____________ _______Gastric mucosa is sensitive to changes in hemod Ebook Critical care update 2017: Part 2 healthy stomach. These mechanisms can cause mucosal damage, but need the presence of gastric acid to cause major ulcerations and gastric bleeding. Without acid, mucosal damage Is onlyminimal. This is the rationale for the use of add-suppressive drugs such as PPI or H2RA for pharmacological prophyla Ebook Critical care update 2017: Part 2xis.4Recent studies report a very low incidence of stress ulcer-related bleeding due to effective pharmacological and nonpharmacological prophylacticEbook Critical care update 2017: Part 2
measures, therefore risk of mortality appears to be low.7Main risk factors for bleeding are mechanical ventilation for more than ‘18 hours, coagulopatAcid Suppression in Critically III: Is It Really Necessary?Samir SahuỈ INTRODUCTION____________ _______Gastric mucosa is sensitive to changes in hemod Ebook Critical care update 2017: Part 2e), cardiogenic shock, bum patients, those with craniocerebral injury, acute renal failure (Gr B evidence) and history of an upper gastrointestinal bleeding within the past 12 months, severe sepsis or septic shock, known peptic ulcer disease, post-kidney or liver nansplantation and those patients ta Ebook Critical care update 2017: Part 2king nonsteroidal anti-inflammatory drugs (NSAIDs) or high-dose glucocorticoids (Gr c evidence). Based upon cunent evidence, these patients should recEbook Critical care update 2017: Part 2
eive pharmacological ulcer prophylaxis.4Almost universal use of stress ulcer prophylaxis in intensive care unit (ICỤ) is due to die above mentioned riAcid Suppression in Critically III: Is It Really Necessary?Samir SahuỈ INTRODUCTION____________ _______Gastric mucosa is sensitive to changes in hemod Ebook Critical care update 2017: Part 2ly ill patients.3Due to the fact that acid suppressive medicalions can effectively lower the SRMD-related bleeding, which are clinically important as shown in many meta-analyses, though based on low-quality studies, national and international guidelines have endorsed this practice in patients with r Ebook Critical care update 2017: Part 2isk factors for bleeding? There are several trials and metaanalyses comparing PPI to H2RA. Most of them favor PPI with respect to reduction of bleedinEbook Critical care update 2017: Part 2
g rates. PPI are the agents of choice in SUP.2ị ADVERSE EFFECTSWe ingest padiogens during routine feed and gastric acid aơs as a natural barrier againAcid Suppression in Critically III: Is It Really Necessary?Samir SahuỈ INTRODUCTION____________ _______Gastric mucosa is sensitive to changes in hemod Ebook Critical care update 2017: Part 2PTER 33: Acid Suppression in Critically III: Is It Really Necessary?this acid barrier by pharmacological means takes away (his defense mechanism. This leads (O overgrowth of bacteria in upper tract- *bis phenomenon is more evident with agents with stronger and longer acid suppressing effect like PPI Ebook Critical care update 2017: Part 2- Moreover. acid-suppressing agents can also alter leukocyte function. This results in both intestinal infections such as Clostridium difficilc-assQciEbook Critical care update 2017: Part 2
aied diarrhea (CDAD) and also to extraintestinal infections like pneumonia (via retrograde microaspiratỉon).4 Of these infections, c. diflkite is the Acid Suppression in Critically III: Is It Really Necessary?Samir SahuỈ INTRODUCTION____________ _______Gastric mucosa is sensitive to changes in hemod Ebook Critical care update 2017: Part 2e form is normally inhibited by gastric add and spores are resistant to ir. Suppression of this add milieu (gastric pH >5) leads to increased survival of the vegetative forms, which are the main culprit in COAD as the stool of infected individuals contains tenfold mon: vegetative forms than spores. Ebook Critical care update 2017: Part 2Due to the same reason, frequent COAD relapses and recurrent diseases are more common in patients on PPI therapy. ’3Tne role of acid suppression as aEbook Critical care update 2017: Part 2
risk factor for pneumonia is unclear but remains likely. Larger randomized prospective trials are warranted to resolve this issue.3Patients with liverAcid Suppression in Critically III: Is It Really Necessary?Samir SahuỈ INTRODUCTION____________ _______Gastric mucosa is sensitive to changes in hemod Ebook Critical care update 2017: Part 2k of spontaneous bacterial peritonitis and higher rates of pneumonia and C.DAD.”Due to polypharmacy, there are important drug-drug interactions with PPI, one of the most important clinically, is between the antiplatelet agent clopidogrel and various PPI. A study reported increased cardiovascular eve Ebook Critical care update 2017: Part 2nts in patients taking both clopidogrel and PPL7 Moreover, use of PPI has been associated with liver toxicity manifesting as ữansaminitis, bone marrowEbook Critical care update 2017: Part 2
suppression manifesting as thiumbocytopenia and hypomagnesemia/Enteral nutrition seems to be protective against stress nicer related bleeding and addAcid Suppression in Critically III: Is It Really Necessary?Samir SahuỈ INTRODUCTION____________ _______Gastric mucosa is sensitive to changes in hemod Ebook Critical care update 2017: Part 2 enteral nutrition could be a viable alternative Io pharmacological SUP?19 It was observed that ill entcrally fed patients, who have additional SUP therapy, tire incidence of pneumonia was increased compared to patients on parenteral nutrition. In this subgroup, an increase in mortality was also obs Ebook Critical care update 2017: Part 2erved.10CONCLUSIONThe triad of Stress-related increased gastric acid formation, reduced perfusion of GI mucosa due to sepsis or shock and reduction ofEbook Critical care update 2017: Part 2
protective mucosal barrier make the critically ill patients more vulnerable to G1 bleed due to SRMD or ulcer This leads toalrnost universal applicatiAcid Suppression in Critically III: Is It Really Necessary?Samir SahuỈ INTRODUCTION____________ _______Gastric mucosa is sensitive to changes in hemod Ebook Critical care update 2017: Part 2practice has not resulted in decreases mortality ami its universal use is questioned as this practice may be associated with some risk. Nosocomial pneumonia and c. difficile aie among the two most serious association of this practice. Thus risk benefit needs to bl! balanced carefully before selectin Ebook Critical care update 2017: Part 2g SUP. Other less risky strategies like early enteral feeding or restricting SUP to Very high-risk patients during early 1C.IJ stay, needs to be evaluEbook Critical care update 2017: Part 2
ated in prospective randomized trials.i REFERENCES• Stclman ft. Metz cc RilhKhysickg/ and rnXWiB el stress liter m rctnaw care I (lit pa-wits J Oil CaAcid Suppression in Critically III: Is It Really Necessary?Samir SahuỈ INTRODUCTION____________ _______Gastric mucosa is sensitive to changes in hemod Ebook Critical care update 2017: Part 2l patients: a -jsaraii: review and meta-analysis. Crtl Care Meú. 2013:41: 603-705.3Buxidga-fi L Kail A Tad® F Fiwrhon cl sHers-refe-aj liter b^eơns al ire inleube cars nt Rife and banefits nt stress uar prap-r/>aGọi ngay
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