Risk factors and management of stress ulcers among adult patients in Kenyatta National Hospital critical care unit
Abstract
Background: Stress ulcers are gastrointestinal ulcerations that develop due to
extreme physiological stress. Patients in the critical care unit: and high dependence
units have greatest risks of developing stress ulcers. Endoscopy results show that up
to 75% of critical care patients develop ulcers within 72 hours of admission. There is
scant literature on the risk factors and management of stress ulcers in these patients in
resource limited setting and hence the impetus for this study.
Objectives: To determine the incidence, risk factors and management of stress ulcers
among adult patients admitted to Kenyatta National Hospital critical care unit.
Method: This was a tertiary hospital based retrospective cohort study among 186
critically ill adult patients admitted to Kenyatta National Hospital Critical Care Unit
between January and December, 2012. The study involved random review of patient
files to abstract the information relevant to risk factors and management of stress
ulcers. This information was entered into a designed data collection tool.
Data management and Analysis: The data was keyed into a Microsoft excel
database and was analyzed using Statistical Package for Social Sciences version 19.0
and STATA version 9.0 software. Statistical significance was determined at 95 %
confidence intervals. P- values '::;0.05were considered significant. Logistic regression
was performed to determine the risk factors for development of stress ulcers. Manual
forward stepwise model building was used to select the most important predictors for
the development of stress ulcers.
Results: This study had more males (57.5%) than females. The mean age was 40.4
years (SD, ±17.0). The incidence of stress ulcers was found to be 36.6%. Diagnosis
for stress ulcers was mainly based on clinical signs of epigastric tenderness (88.2%).
Mechanical ventilation was the most important risk factor for stress ulcer
development (adjusted OR: 43.76, 95% CI [5.067, 377.9]. Ranitidine and omeprazole
were the most preferred drugs for prophylaxis (71.5 and 20.6% respectively). More
than three-quarters ofthe patients received prophylaxis as per the guidelines although
3.8% of patients who qualified for the same did not get.
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Ranitidine was the preferred treatment for patients that developed stress ulcers
(57.4%). Antibiotics (adjusted OR: 0.044,95% CI [0.002, 0.936]) and
benzodiazepines (adjusted OR: 0.074,95% CI [0.013, 0.419J were found to confer
protection, while use of prophylactic agents did not confer any protection (p=0.003).
The stress ulcer protective properties of aspirin (adjusted OR: 0.021 [0.00,0.044])
were unclear. The most important predictor for development of stress ulcer was
hospital stay for more than 7 days (adjusted OR: 11.885,95% CI [3.923, 36.9]).
Use of steroidal drugs and anticoagulants increased the odds of developing stress
ulcers (adjusted OR: 7.184, 95% CI [1.082,47.706]).
Among the patients that developed stress ulcers, 51% were discharged, while the rest
died.
Conclusion: The incidence of stress ulcers was found to be high at 36.6%, and may
be higher since diagnosis depended on subjective clinical signs which may not be as
accurate as endoscopy. Long duration of hospitalization contributed to stress ulcer
development. Current prophylaxis was poor because more than half of the patients
who developed stress ulcers had prophylaxis. We recommend review and optimal
utilization of guidelines on stress ulcer diagnosis and prophylaxis for improved care
and to reduce morbidity and mortality.
Citation
Master of pharmacy (Clinical Pharmacy)Publisher
University of Nairobi