摘要

Importance:Proton pump inhibitors (PPIs) or histamine-2 receptor blockers (H2RBs) are often prescribed for patients as stress ulcer prophylaxis drugs in the intensive care unit (ICU). The comparative effect of these drugs on mortality is unknown.
Objective:To compare in-hospital mortality rates using PPIs vs H2RBs for stress ulcer prophylaxis.
Design, Setting, and Participants:Cluster crossover randomized clinical trial conducted at 50 ICUs in 5 countries between August 2016 and January 2019. Patients requiring invasive mechanical ventilation within 24 hours of ICU admission were followed up for 90 days at the hospital.
Interventions:Two stress ulcer prophylaxis strategies were compared (preferential use with PPIs vs preferential use with H2RBs). Each ICU used each strategy sequentially for 6 months in random order; 25 ICUs were randomized to the sequence with use of PPIs and then use of H2RBs and 25 ICUs were randomized to the sequence with use of H2RBs and then use of PPIs (13 436 patients randomized by site to PPIs and 13 392 randomized by site to H2RBs).
Main Outcomes and Measures:The primary outcome was all-cause mortality within 90 days during index hospitalization. Secondary outcomes were clinically important upper gastrointestinal bleeding, Clostridioides difficile infection, and ICU and hospital lengths of stay.
Results:Among 26 982 patients who were randomized, 154 opted out, and 26 828 were analyzed (mean [SD] age, 58 [17.0] years; 9691 [36.1%] were women). There were 26 771 patients (99.2%) included in the mortality analysis; 2459 of 13 415 patients (18.3%) in the PPI group died at the hospital by day 90 and 2333 of 13 356 patients (17.5%) in the H2RB group died at the hospital by day 90 (risk ratio, 1.05 [95% CI, 1.00 to 1.10]; absolute risk difference, 0.93 percentage points [95% CI, -0.01 to 1.88] percentage points; P = .054). An estimated 4.1% of patients randomized by ICU site to PPIs actually received H2RBs and an estimated 20.1% of patients randomized by ICU site to H2RBs actually received PPIs. Clinically important upper gastrointestinal bleeding occurred in 1.3% of the PPI group and 1.8% of the H2RB group (risk ratio, 0.73 [95% CI, 0.57 to 0.92]; absolute risk difference, -0.51 percentage points [95% CI, -0.90 to -0.12 percentage points]; P = .009). Rates of Clostridioides difficile infection and ICU and hospital lengths of stay were not significantly different by treatment group. One adverse event (an allergic reaction) was reported in 1 patient in the PPI group.
Conclusions and Relevance:Among ICU patients requiring mechanical ventilation, a strategy of stress ulcer prophylaxis with use of proton pump inhibitors vs histamine-2 receptor blockers resulted in hospital mortality rates of 18.3% vs 17.5%, respectively, a difference that did not reach the significance threshold. However, study interpretation may be limited by crossover in the use of the assigned medication.
Trial Registration:anzctr.org.au Identifier: ACTRN12616000481471.

译文

重要性: 质子泵抑制剂 (PPIs) 或组胺-2 受体阻滞剂 (H2RBs) 通常作为重症监护病房 (ICU) 患者的应激疮预防药物。这些药物对死亡率的比较效果尚不清楚。
目的: 比较使用 PPIs 与 H2RBs 预防应激性溃疡的住院死亡率。
设计、设置和参与者: 2016年8月至 2019年1月在 5 个国家的 50 个 icu 进行的集群交叉随机临床试验。ICU 入院 24 小时内需要有创机械通气的患者在医院随访 90 天。
干预: 比较两种应激性溃疡预防策略 (PPIs 优先使用 vs H2RBs 优先使用)。每个 ICU 按随机顺序连续使用每个策略 6 个月; 25 个 ICUs 被随机分配到使用 PPIs 的序列,然后使用 H2RBs,25 个 ICUs 被随机分配到使用 H2RBs 的序列,然后使用 PPIs(13 436 名患者按部位随机分配到 PPIs,13 392 名患者按部位随机分配到 H2RBs)。
主要结果和措施: 主要结果是指数住院期间 90 天内的全因死亡率。次要结果是临床上重要的上消化道出血、艰难梭菌感染、 ICU 和住院时间。
结果: 在 26 982 名随机患者中,154 名选择退出,26 828 名被分析 (平均 [SD] 年龄,58 [17.0] 岁; 9691 [36.1%] 是女性)。死亡率分析中有 26 771 名患者 (99.2%); 13 2459 名患者中的 415 (18.3%) 在 PPI 组中,2333 天死于医院,356 名患者 (17.5%) 中,名患者 () 在 H2RB 组中,天死于医院 (风险比, 1.05 [95% CI,1.00 至 1.10]; 绝对风险差异,0.93 个百分点 [95% 置信区间,-0.01 至 1.88] 个百分点; p   =  .054)。据估计,按 ICU 站点随机分配到 PPIs 的患者中有 4.1% 实际接受了 H2RBs,按 ICU 站点随机分配到 H2RBs 的患者中有 20.1% 实际接受了 PPIs。临床上重要的上消化道出血发生在 1.3% 的 PPI 组和 1.8% 的 H2RB 组 (风险比,0.73 [95% CI,0.57 至 0.92]; 绝对风险差, -0.51 个百分点 [95% 置信区间,-0.90 至-0.12 个百分点]; p   =  。 009)。艰难梭菌感染率、 ICU 和住院时间在治疗组之间没有显著差异。在 PPI 组的 1 名患者中报告了一项不良事件 (过敏反应)。
结论和相关性: 在需要机械通气的 ICU 患者中,使用质子泵抑制剂和组胺-2 受体阻滞剂预防应激疮的策略导致医院死亡率为 18.3% 和 17.5%, 分别为未达到显著性阈值的差异。然而,研究解释可能受到指定药物使用交叉的限制。
试用注册: anzctr.org.au 标识符: actrn12616000481471。

Mechanical ventilation

重症 通气 治疗方法
概述  :  

机械通气是利用机械装置来代替、控制或改变自主呼吸运动的一种通气方式。机械通气可分为无创机械通气和有创机械通气,前者包括各种类型的面罩通气,后者包括气管插管通气。选择和使用合适的机械通气技术需要医生理解呼吸力学。   作用机制 正常吸气时胸腔内产生的负压使空气和肺泡之间形成压力差,这种压力差使空气流向肺内。机械通气时,该压力差由气源压力升高(正压通气)所致。气道峰压测压点在气道开口处,呼吸机常规显示该监测数值。气道峰压是驱

mechanical 英 [məˈkænɪkl] 美 [məˈkænɪkl]

释义   adj. 机械的;力学的;呆板的;无意识的;手工操作的

例句   This should be a largely mechanical process.这应该是一个很大程度上的机械过程。

 

ventilation 英 [ˌventɪˈleɪʃn] 美 [ˌventɪˈleɪʃn]

释义   n. 通风设备;空气流通

例句   If humidity not within the set point, turn on external ventilation.如果湿度不在设置点内,那么打开外部通风。

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