OPTIMAL THERAPY FOR STRESS GASTRITIS

Objective The authors compared the results of sucralfate versus H-2 bl ocker +/-, antacid as prophylaxis for stress ulceration in an intensiv e cafe unit patient population. Summary Background Data Stress ulcerat ion carries high morbidity and mortality for the patient who is critic ally 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 efficac y of sucralfate prophylaxis for stress ulceration and its the effect o n the nosocomial pneumonia rate is controversial. The financial implic ations of sucralfate prophylaxis versus H-2 blocker-based acid neutral ization therapy has not been studied. Methods Ninety-eight injured pat ients who were critically ill and who required intubation and intensiv e care unit (ICU) support for at least 72 hours without gastric feedin g were randomized and received either maximal H-2 blocker infusion the rapy (continuous infusion of ranitidine at 0.25 mg/kg/hr after a loadi ng dose of 0.5 mg/kg) plus antacids (for persistent pH < 4) or sucralf ate (1 g every 6 hours via nasogastric tube) for stress ulcer prophyla xis. Efficacy in preventing stress ulcer complications was determined. The impact of each therapeutic approach on development of nosocomial pneumonia was evaluated. The charges/cost for each approach was analyz ed. Results Heme-positive gastric aspirates occurred in 99% of the pat ients, whereas 12 (7 in the H-2 blocker group and 5 in the sucralfate group) were grossly positive for blood. However, only one from each gr oup required transfusion, and one in the H-2 blocker group required op eration. Gastric colonization preceded tracheobronchial colonization i n five patients in the H-2 blocker group and one patient in the sucral fate group; simultaneous gastric/oropharyngeal colonization preceded p ositive tracheobronchial growth in six patients who received H-2 block er and one patient who received sucraifate. The overall pneumonia rate was 27.5% in the H-2 blocker group and 20.8% in the sucralfate group (p = 0.48). Days on ventilator were 13.5 versus 9.1, (p = 0.06), ICU l engths 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 H-2 blocker group an d sucralfate group, respectively. Based on current charges and protoco ls for optimal H-2 blocker and sucralfate prophylaxis, use of sucralfa te lather than H-2 blockers would decrease the annual cost by more tha n $30,000 per bed. Conclusions Sucralfate is as efficacious as maximal H-2 blocker therapy for stress ulceration prophylaxis, and may have a beneficial effect on the incidence of nosocomial pneumonia. Sucralfat e has a major reduction on nursing requirements for stress ulcer proph ylaxis and would save approximately $30,000 per ICU bed per year in pa tient charges.