Helicobacter pylori en pacientes con gastritis

ANNALS OF SURGERY Vol. 220, No. 3, 353-363 © 1994 J. B. Lippincott Company

Optimal Therapy for Stress Gastritis
Ronald V. Maier, M.D., Donna Mitchell, R.N., and Larry Gentilello, M.D.

From the Department of Surgery, Harborview Medical Center, University of Washington, Seattle, Washington

Objective
The authors compared the results of sucralfate versus H2 blocker ± antacid as prophylaxisfor stress ulceration in an intensive care unit patient population.

Summary Background Data
Stress ulceration carries high morbidity and mortality for the patient who is critically ill. Gastric acid neutralization is an effective prophylaxis. The impact of increased gastric colonization with bacterial pathogens on nosocomial pneumonia after acid neutralization is unclear. The efficacy ofsucralfate prophylaxis for stress ulceration and its the effect on the nosocomial pneumonia rate is controversial. The financial implications of sucralfate prophylaxis versus H2 blocker-based acid
neutralization therapy has not been studied.

Methods
Ninety-eight injured patients who were critically ill and who required intubation and intensive care unit (ICU) support for at least 72 hours withoutgastric feeding were randomized and received either maximal H2 blocker infusion therapy (continuous infusion of ranitidine at 0.25 mg/kg/hr after a loading dose of 0.5 mg/kg) plus antacids (for persistent pH < 4) or sucralfate (1 g every 6 hours via nasogastric tube) for stress ulcer prophylaxis. Efficacy in preventing stress ulcer complications was determined. The impact of each therapeuticapproach on development of nosocomial pneumonia was evaluated. The charges/cost for each approach was analyzed.

Results
Heme-positive gastric aspirates occurred in 99% of the patients, whereas 12 (7 in the H2 blocker group and 5 in the sucralfate group) were grossly positive for blood. However, only one from each group required transfusion, and one in the H2 blocker group required operation.Gastric colonization preceded tracheobronchial colonization in five patients in the H2 blocker group and one patient in the sucralfate group; simultaneous gastric/oropharyngeal colonization preceded positive tracheobronchial growth in six patients who received H2 blocker and one patient who received sucralfate. The overall pneumonia rate was 27.5% in the H2 blocker group and 20.8% in the sucralfategroup (p = 0.48). Days on ventilator were 13.5 versus 9.1, (p = 0.06), ICU lengths of stay were 14.7 versus 10.2 (p = 0.06), and hospital lengths of stay were 27.8 versus 20.0 (p = 0.029) for the H2 blocker group and sucralfate group, respectively. Based on current charges and protocols for optimal H2 blocker and sucralfate prophylaxis, use of sucralfate rather than H2 blockers would decrease theannual cost by more than $30,000 per bed.

Conclusions
Sucralfate is as efficacious as maximal H2 blocker therapy for stress ulceration prophylaxis, and may have a beneficial effect on the incidence of nosocomial pneumonia. Sucralfate has a major reduction on nursing requirements for stress ulcer prophylaxis and would save approximately $30,000 per ICU bed per year in patient charges.

353354

Maier, Mitchell, and Gentilello

Ann. Surg. * September 1994

Aggressive stress gastritis prophylaxis has become the standard of care in the intensive care unit (ICU) setting to prevent the high morbidity and mortality associated with acute gastric hemorrhage, or rarely, perforation in the patient who is critically ill.' Routine endoscopy for the patient who is critically ill hasdocumented the nearly ubiquitous occurrence of gastric ulceration that occurs rapidly after admission to the ICU. 1-2 In addition, multiple studies have documented the efficacy of acid neutralization or inhibition ofacid release in the prevention of stress ulceration and its associated high morbidity.39 The use of antacids per nasogastric (NG) tube and titrated to maintain a pH greater than 4 has a...