N. M. Grimmer1, B. McKinzie1, P. L. Ferguson1, E. Chapman1, M. Dorlon1, E. A. Eriksson1, B. Jewett1, S. M. Leon1, A. R. Privette1, S. M. Fakhry1 1Medical University Of South Carolina,Charleston, Sc, USA
Introduction: Stress gastropathy is a complication of ICU stay with high morbidity and mortality, but a low incidence of occurrence. Prophylaxis against stress gastropathy is recommended in national guidelines, and the standard of care is pharmacologic acid suppressive therapy. There are data that support the concept that patients tolerating enteral nutrition have sufficient gut blood flow to obviate the need for prophylaxis; however, no robust studies exist. The current standard in our academic level 1 trauma center is to discontinue pharmacologic prophylaxis once enteral nutrition is providing full caloric requirements. This retrospective cohort study assesses the incidence of clinically significant gastrointestinal bleeding in surgical-trauma intensive care unit (STICU) patients at risk of stress gastropathy secondary to mechanical ventilation in this setting.
Methods: A retrospective chart review was performed of adult patients admitted to the STICU between 2008 and 2013. The primary objective was to assess the incidence of clinically significant gastrointestinal bleeding. Secondary objectives include the rates of ventilator-associated pneumonia (VAP), Clostridium difficile infection (CDI), and mortality. Patients were included if they received full enteral nutrition while on mechanical ventilation. Exclusion criteria included any coagulopathy, glucocorticoid use, prior-to-admission acid suppressive therapy use for other indications, direct trauma or surgery to the stomach, failure to tolerate enteral nutrition goal, and orders to allow natural death. Patients were excluded if pharmacologic stress ulcer prophylaxis was not discontinued during intensive care unit stay.
Results: A total of 239 patients were included. The median age was 42 years, 81.2% were male, and 96.7% were trauma patients. The incidence of clinically significant gastrointestinal bleeding was 0.42%, with a subset analysis of traumatic brain injury patients yielding an incidence of 0.57%. Rates of VAP and CDI were low at 1.24 cases/1000 vent days and 0.71 events/1000 patient days, respectively. Hospital all-cause mortality was 1.7%. An average $242 per patient was saved by discontinuing medication. The incidence of clinically significant gastrointestinal bleeding was comparable to historic rates of bleeding with provision of pharmacologic stress ulcer prophylaxis. The patient population studied is limited to predominantly trauma patients with mechanical ventilation and/or traumatic brain injury as risks for stress gastropathy.
Conclusion: We conclude that stress gastropathy is rare in this population. Surgical trauma patients who are at risk for stress gastropathy may not benefit from pharmacologic prophylaxis once they tolerate enteral nutrition. Pharmacologic prophylaxis was safely discontinued in this patient population. Further investigation is warranted to determine whether continued prophylaxis after attaining enteral feeding goals is detrimental.