LETTER
Stress Ulcer Prophylaxis in Ventilated Patients
J. G. Moore
15 November 1994 | Volume 121 Issue 10 | Pages 816-817
TO THE EDITOR:
The data of Prod'hom and colleagues [1] clearly implicate acid-reducing strategies in the genesis of intensive care unit-based nosocomial pneumonia. Although the incidence of nosocomial pneumonia reported in their study (21.7% [53 of 244 patients]) was somewhat less than that noted in earlier reports (27%) [2], it still exceeds the incidence of significant gastrointestinal bleeding events in the intensive care unit (<5%) for which acid-reducing strategies were originally designed [3]. Thus, a Hobson's choice is created with acid suppression in the intensive care unit: Too little results in increased susceptibility to gastrointestinal bleeding events, and too much results in increased susceptibility to nosocomial pneumonia. The critical range of intragastric pH required to protect against both of these complications is unknown but is probably narrow. Intragastric pH values of 3.5 or greater provide stress ulcer prophylaxis [3], whereas prophylactic benefit against nosocomial pneumonia has been shown to begin at or less than this same value [4]. If control of gastric acidity is indeed important in preventing gastrointestinal bleeding and nosocomial pneumonia, more prospective studies similar to that by Prod'hom and colleagues [1] and Cook and associates [5] are needed. Cook and colleagues [5] recommended stress ulcer prophylaxis only for patients in an intensive care unit who had coagulopathy or required mechanical ventilation—constituting 37% of their study sample. These studies, however, need more detailed information on gastric pH measurements—not reported by Cook and colleagues and measured only twice daily by Prod'hom and associates—to include more frequent measurements. Indeed, Prod'hom and coworkers arrived at the same conclusion based on the observation that half of their mechanically ventilated patients had mean intragastric pH values greater than 4.0 and, presumably, would therefore not require any stress ulcer prophylaxis.
1. Prod'hom G, Leuenberger P, Koerfer J, Blum A, Chiolero R, Schaller MD, et al. Nosocomial pneumonia in mechanically ventilated patients receiving antacid, ranitidine, or sucralfate as prophylaxis for stress ulcer. A randomized controlled trial. Ann Intern Med. 1994; 120:653-62.
2. George D. Epidemiology of nosocomial ventilation-associated pneumonia. Infect Control Hosp Epidemiol. 1993; 14:163-9.
3. Shuman RB, Schuster DP, Zuckerman GR. Prophylactic therapy for stress ulcer bleeding: a reappraisal. Ann Intern Med. 1987; 106:562-7.
4. Heyland D, Bradley C, Mandell L. Effect of acidified internal feedings on gastric colonization in the critically ill patient. Crit Care Med. 1992; 20:1388-94.
5. Cook DJ, Fuller HD, Guyatt GH, Marshall JC, Leasa D, Hall R, et al. Risk factors for gastrointestinal bleeding in critically ill patients Canadian Critical Care Trials Group. N Engl J Med. 1994; 330:377-81.
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