Ulcer Prophylaxis in ICU

[totalbodypain]

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So I have a bunch of neuro patients in the unit that are trached on tube feeds and still on ulcer prophylaxis. Anybody know of any papers that show one way or another whether you have to continue ulcer prophylaxis in ventilated patients once they are tolerating tube feeds at goal. I'm not finding anything on my end that trully answers this question. Thanks in advance.

 

[deleted87716]

So I have a bunch of neuro patients in the unit that are trached on tube feeds and still on ulcer prophylaxis. Anybody know of any papers that show one way or another whether you have to continue ulcer prophylaxis in ventilated patients once they are tolerating tube feeds at goal. I'm not finding anything on my end that trully answers this question. Thanks in advance.

Maybe this?

http://www.cja-jca.org/cgi/content/full/52/6/650

 

[totalbodypain]

Maybe this?

http://www.cja-jca.org/cgi/content/full/52/6/650

Thanks KentW but thats actually the one I've got. They imply in the discussion that enteral feedings were protective but not whether prophylaxis should be continued after feeds, d/ced and certainly didn't provide any study to argue one way or the other. Some other studies seem to argue that enteral feedings are as effective as H2 blocker/decrease GI bleeding but these studies are fraught with all kinds of problems...
(MacLaren R, Jarvis CL, Fish DN. Use of enteral nutrition for stress ulcer prophylaxis. Ann Pharmacother. 2001;35:1614-1623.
Raff T, Germann G, Hartmann B. The value of early enteral nutrition in the prophylaxis of stress ulceration in the severely burned patient. Burns. 1997;23:313-318. ) Not enough power, use of H2 prophylaxis with feeds and a lack of a consistent regimen for feeds.
Anyway, Mabey I am not going to be coming up with an answer any time soon. Had one attending arguing one point and a counter argument from the CC fellow. Thanks for the help

 

[JackBauERfan]

Thanks KentW but thats actually the one I've got. They imply in the discussion that enteral feedings were protective but not whether prophylaxis should be continued after feeds, d/ced and certainly didn't provide any study to argue one way or the other. Some other studies seem to argue that enteral feedings are as effective as H2 blocker/decrease GI bleeding but these studies are fraught with all kinds of problems...
(MacLaren R, Jarvis CL, Fish DN. Use of enteral nutrition for stress ulcer prophylaxis. Ann Pharmacother. 2001;35:1614-1623.
Raff T, Germann G, Hartmann B. The value of early enteral nutrition in the prophylaxis of stress ulceration in the severely burned patient. Burns. 1997;23:313-318. ) Not enough power, use of H2 prophylaxis with feeds and a lack of a consistent regimen for feeds.
Anyway, Mabey I am not going to be coming up with an answer any time soon. Had one attending arguing one point and a counter argument from the CC fellow. Thanks for the help

hmm one of my attendings was discussing this same topic today, but mainly focusing on the fact of the clear indications to prophylax. We round again tommorow morning with same attending so I'll ask him if he knows of any specific papers. He's really big on them, since like he mentioned for us to go and read a few of the ones he cited (one of course was the rivers septic early goal therapy one haha). So I'm sure he might have an idea, if our great forums here can not answer them!

 

[KGUNNER1]

This may be impossible to answer with great EBM to support it. It is really a reflection of the times.

When a large number of the stress ulcer prophylaxis trials were being done, it was common to withhold enteral feeds for a number of reasons such as "too sick", ileus, "we should just rest the bowel for a few days", and even being on one pressor at very low dose. TPN was used a lot more than current practice and even just hanging a bag of D5 1/2NS for a couple days "couldn't be bad".

We now know all the benefits of early enteral feeding, and all the above reasons to withhold them don't add up anymore.

We've also seen a dramatic decrease in significant GI bleeding from gastritis during this nutritional renascence.

So was the decrease in GIB due to the enteral feeds, or the H2 blockers? If the H2 blockers are good, shouldn't the PPI's be even better? If you don't have an active bleeder, H2 blockers and PPI's are equally effective.

We do know how to risk stratify some of the higher risk patients, such as those ventilated and coagulopathic, but we really don't have a good study looking at withdrawing their use in the ICU setting.

If I remember correctly, I think Deborah Cook either did a Cochrane or regular review on this a few years back.

Good question.

Kyle