Do patients with tracheostomy tubes still need stress ulcer prophylaxis?

Comment by InpharmD Researcher

There is an overall lack of data and specific recommendations regarding stress ulcer prophylaxis for patients with tracheostomy tubes. The Eastern Association for the Surgery of Trauma (EAST) guideline does not offer specific guidance in this context. However, one institutional guideline highlights that for patients transitioning from mechanical ventilation to a tracheostomy collar, prophylaxis can be discontinued to avoid unnecessary treatment. Notably, one dated study with several limitations on tracheotomized patients with tetanus found that pharmacologically increasing gastric pH with ranitidine may elevate the risk of pneumonia. Another study found that stress ulcer prophylaxis was a risk factor for tracheal colonization in tracheotomized patients, caused by gram-negative pathogens. Due to the limited available data, there is no clear consensus on the necessity of stress ulcer prophylaxis for tracheostomy patients.

  

PubMed: (stress ulcer) AND (tracheostomy)= 14 results

Background

The 2008 practice guideline from the Eastern Association for the Surgery of Trauma (EAST) discusses the necessity of stress ulcer prevention in the trauma population. Prevention is advised for all patients with mechanical ventilation, coagulopathy, traumatic brain injury, and major burn injury (Level 1 recommendation). It is also suggested for all intensive care unit (ICU) patients with multi-trauma, sepsis, and acute renal failure (Level 2 recommendation). The panel did not offer any guidance regarding stress ulcer prevention for patients with tracheostomy. [1]

Due to the absence of sufficient data, institutional policies were referred to assess the requirement for stress ulcer prevention in patients with tracheostomy tubes. One protocol emphasized the importance of avoiding unnecessary stress ulcer prophylaxis for ICU patients. It was noted that patients receiving mechanical ventilation are eligible for prophylaxis using histamine-2 receptor antagonists or proton pump inhibitors. However, prophylaxis can be discontinued once a patient transitions to a tracheostomy collar. [2]

References:

[1] Guillamondegui OD, Gunter OL, Bonadies JA, et al. Practice Management Guideline for Stress Ulcer Prophylaxis. Published 2008. Accessed September 21, 2023. https://www.east.org/Content/documents/practicemanagementguidelines/stress-ulcer-prophylaxis%20.pdf
[2] WakeMed. Avoidance of Unnecessary Stress Ulcer Prophylaxis (ICU Protocol). Published February 10, 2021. Accessed September 21, 2023. https://www.wakemed.org/assets/documents/general-surgery-guidelines/icu-guidelines/antiacid-thearpy-icu.pdf
Literature Review

A search of the published medical literature revealed 2 studies investigating the researchable question:

Do patients with tracheostomy tubes still need stress ulcer prophylaxis?

Please see Tables 1-2 for your response.

 

Gastric colonization and pneumonia in intubated critically ill patients receiving stress ulcer prophylaxis: a randomized, controlled trial

Design

Randomized, controlled trial

N= 34

Objective

To study the effects of pharmacologically increasing gastric pH on gastric colonization and the development of pneumonia in intubated critically ill patients

Study Groups

Ranitidine Group (n= 16)

Control Group (n= 18)

Inclusion Criteria

Tracheotomized patients admitted to ICU with tetanus

Exclusion Criteria

Pneumonia before tracheostomy or had received ranitidine before randomization

Methods

Eligible patients were randomly assigned to either IV ranitidine (50 mg every 6 hours) or control (no prophylaxis) groups within 24 hours of the tracheal intubation. All patients received treatment for tetanus and intermittent nasogastric feedings (300 to 400 mL every 4 hours). Tracheal secretions and gastric aspirates were processed for bacterial culture. Patients were studied daily until 48 hours after tracheal extubation. 

Duration

 Follow-up: 48 hours after tracheal extubation

Outcome Measures

 Occurrence rate of colonization and pneumonia

Baseline Characteristics

  

Ranitidine Group (n= 16)

Control Group (n= 18)

  

Age, years

 27 26   

Female

4 7   

Maximum tetanus severity score (17)*

 11 (4-16) 10 (6-16)  

Days of intubation

 7.5 (3-28)  12.5 (3-63)   

Patients requiring mechanical ventilation

 5 4  
Deaths 11 7  

Data are presented as median (range). 

* Tetanus score (17) is obtained by adding points assigned to the distribution of rigidity, the frequency and location of spasms, and vital parameters. It can range from 0 to 20. A score of ≥4 indicates mild tetanus, 5-10 moderate tetanus, and 10-20 severe tetanus.

Results

Endpoint

Ranitidine Group (n= 16)

Control Group (n= 18)

p-value 

Gross gastric bleeding

5

6

--

Occult bleeding

13

10

 > 0.05

Gastric pH (range)

4.7 (3.6-6.1)

2.1 (1.2-4.9)

 < 0.05

Gastric colonization

15

18

 --

Pneumonia

13

9

 < 0.01

Bacteriology in intubated critically ill patients receiving stress ulcer prophylaxis and untreated controls

Organisms causing pneumonia *

Klebsiella spp.

Staphyloccocus aureus

Pseudomonas spp.

Proteus spp.

Escherichia coli

Total

 

9

4

1

0

0

14 

 

5

4

1

1

0

11

 -- 

Organisms colonizing stomach *

Klebsiella

Staphyloccocus aureus

Pseudomonas spp.

Proteus spp.

Escherichia coli

 

14

2

2

0

1

 

12

7

4

1

3 

 -- 

Organisms colonizing the trachea *

Klebsiella

Staphyloccocus aureus

Pseudomonas spp.

Proteus spp.

Escherichia coli

 

7

5

0

1

2 

 

8

6

3

1

2 

 --

Sequence of infection

Stomach-trachea-pneumonia

Stomach-pneumonia

Trachea-pneumonia

Pneumonia without prior colonization of stomach or trachea by the same organism

Total

 

5

4

2

3

14 

 

5

3

1

2

11 

 --

* Total may exceed the number of patients studied. As in some patients, the colonizing bacteria changed after a few days. 

Adverse Events

See result. 

Study Author Conclusions

Pharmacologically increasing gastric pH increases the risk of developing pneumonia in intubated critically ill patients. The pneumonia occurs earlier than in untreated control patients.

InpharmD Researcher Critique

The study has notable limitations, including a lack of observer blinding, which may introduce bias, a small sample size that limits generalizability, and the use of tracheal secretions obtained through tracheostomy instead of bronchoscopic methods to culture pneumonia-causing organisms.

 

References:

Apte NM, Karnad DR, Medhekar TP, Tilve GH, Morye S, Bhave GG. Gastric colonization and pneumonia in intubated critically ill patients receiving stress ulcer prophylaxis: a randomized, controlled trial. Crit Care Med. 1992;20(5):590-593. doi:10.1097/00003246-199205000-00008

 

Stress Ulcer Prophylaxis as a Risk Factor for Tracheal Colonization and Hospital-Acquired Pneumonia in Intensive Care Patients: Impact on Latency Time for Pneumonia

Design

Randomized controlled trial

N= 81

Objective

 To evaluate patients on stress ulcer prophylaxis at the highest risk of both bleeding and pneumonia and to determine which factors influence trachea colonization (TC) in these intensive care unit (ICU) patients

Study Groups

Sucralfate (n= 26)

Ranitidine (n= 27)

Control (n= 28)

Inclusion Criteria

 Age 15 years or older, admitted to the ICU for at least 24 hours, nasogastric tube that were intubated or tracheotomized

Exclusion Criteria

 Presence of hospitalized-acquired pneumonia (HAP) at admission to ICU, immunocompromised status, aspiration at admission, previous intake of antacids, H2 blockers or sucralfate, visible bleeding from stomach or duodenum

Methods

Patients were randomized to be treated with sucralfate 6 g/24 h, ranitidine 300 mg/24 h, or the control group. Sucralfate was given as granules, 4-6 times a day, while ranitidine was given as tablets at 150 mg/24 h. If there was macroscopic bleeding, ranitidine was given parenterally. Stomach pH was measured in the morning on an empty stomach with a Universal Indicator pH-meter (Germany) reporting a range from 1 to 10. Bleeding was measured at each morning, plus presence of fresh blood or blood mass in the stomach aspirate, or with positive hematest.

Duration

 Up to 5 days after ICU admission

Outcome Measures

 Serious bleeding, hazard ratio for colonization of the trachea, hazard ratio for longer latency time between TC and HAP

Baseline Characteristics

  

Sucralfate (n= 26)

Ranitidine (n= 27)

 Control (n= 28)

Age, years

 67.1 68.8 74.2

Female

18 21 24

Intubated

 19 19 22

Tracheotomized

 7 8 6

Mechanical ventilation

 15 16 21

APACHE II

 19.0 19.7 19.3

Underlying disease

Encephalitis

Other

 

7

19

 

8

19

 

2

26

Consciousness

No disturbance

Somnolence

Coma

 

0

11

13

 

2

11

16

 

0

13

15

Relaxation

14

12

12

Sedation

27

21

22

Previous antibiotic treatment

7

7

3

pH value of gastric juice

3.8

4.8

4.2

Results

Endpoint

Sucralfate (n= 26)

Ranitidine (n= 27)

Control (n= 28)

Serious bleeding

1

0

0

Hazard ratio for colonization of trachea

p-value

1.428

0.7134

9.4162

0.0264

--

Hazard ratio for longer latency time between TC and HAP

p-value

0.8951

0.8220

0.7085

0.6123

--

Adverse Events

 N/A

Study Author Conclusions

 Risk factors that accelerated the occurrence of HAP were found to have caused previous colonization. A combination of risk factors increased the likelihood of TC and HAP, and shortened LAT between TC and HAP.

InpharmD Researcher Critique

 The small sample sizes diminish the strength of the findings. The majority of findings were focused on establishing risk factors for colonization or development of hospital-acquired pneumonia.



References:

Muzlovič I, Štubljar D. STRESS ULCER PROPHYLAXIS AS A RISK FACTOR FOR TRACHEAL COLONIZATION AND HOSPITAL-ACQUIRED PNEUMONIA IN INTENSIVE CARE PATIENTS: IMPACT ON LATENCY TIME FOR PNEUMONIA. Acta Clin Croat. 2019;58(1):72-86. doi:10.20471/acc.2019.58.01.10