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Gastric prophylaxis; Should we bother ? If so with what ?
| In this meta-analysis ranitidine significantly reduced the incidence
of clinically important GI bleeding, in the critically ill, when compared
with placebo. There was a non-significant suggestion that ranitidine was
superior to sucralfate.
Level of evidence 1+ |
Citation/s:
Cook DJ, Witt LG, Cook RJ, Guyatt GH. Stress Ulcer Prophylaxis in the Critically
Ill: A Meta-Analysis. The American Journal of Medicine. 1991. 91;519-527
Lead author's name and fax: Deborah J. Cook. McMaster University Ontario
Three-part Clinical Question: What is the effect of different regimens
of gastric protection, in the critically ill, on the rate of bleeding and
mortality ?
Search Terms: Critically ill, sucralfate, ranitidine, meta-analysis
The Review:
Data Sources: : Medline, Embase, Citation Index, pharmaceutical
companies, hand search, Wide search for unpublished data.
Study Selection: Randomized, controlled trials
Data Extraction: Critically ill patients. Outcome data; gastrointestinal
bleeding. Overt bleeding defined as haematemasis, bloody gastric aspirate,
malena or rectal bleeding. Clinically important bleeding was defined as overt
bleeding plus one of the following; (1) decrease in blood pressure of 20mmHg
within 24hrs of bleeding, (2) blood pressure reduction of 10mmHg and a heart
rate increase of 20bpm on orthostatic change, or (3) decrease of 20g/L in
haemoglobin level and transfusion of 2 units of blood within 24hrs.
The studies were multiple independent reviews of individual reports. They were
tested for heterogeneity.
The Evidence:
| Outcome |
Time to Outcome |
Typical CER |
Typical OR |
RRR |
NNT |
p Value |
| H2 blocker vs Sucralfate. Clinically important bleeding |
ICU discharge |
0.02 |
0.95 |
5% |
1019 |
|
| 95% Confidence Intervals: |
0.06 to 15.4 |
|
53 to -5 |
| H2 blocker vs placebo. Clinically important bleeding |
ICU discharge |
0.02 |
0.35 |
65% |
77 |
|
| 95% Confidence Intervals: |
0.15 to .076 |
|
59 to 54 |
| H2 blockers vs Antacids. Clinically significant bleeding |
ICU discharge |
0.02 |
0.85 |
15% |
339 |
|
| 95% Confidence Intervals: |
.45 to 1.56 |
|
92 to -92 |
Comments:
This study demonstrated a RRR of approximately 65% for ranitidine and clinically
significant bleeding when compared with placebo.
There was insufficient data to compare sucralfate with placebo. There was a
non-significant suggestion that ranitidine was superior to sucralfate. Non of
the interventions has a significant effect on mortality.
The authors suggested than further investigation of several areas was merited:
assessment of risk of GI bleeding in different patient groups, a large RCT
comparing ranitidine and sucralfate.
Appraised by: Dr Chris Cairns, Spr in Anaesthetics & Intensive Care.
Edinburgh Royal Infirmary.; Monday, December 23, 2002
Email: Chris.Cairns@btinternet.com
Kill or Update By: Dec 2007
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