There were also questions on the generalizability of ITT to medical ICU patients. In a recent randomized study of 1,200 medical ICU patients, ITT did not significantly reduce hospital mortality overall, and increased mortality in patients with ICU stays < 3 days. However, the ITT group had reduced acquired renal failure, duration of mechanical ventilation, and length of ICU and hospital stay. Difficulty in predicting length of stay is difficult; concerns about the risks of hypoglycemia, resource implications, and assessing the benefit of ITT in different hospitals require further evaluation. canadian pharmacy
Enteral feeding is preferred to parenteral feeding, but aspiration pneumonia is a complication. Bowman and coworkers instituted an evidence-based, enteral feeding protocol in which 78 to 85% of patients reached their enteral feeding goal and aspiration pneumonia rates decreased from 6.8 to 3.2/1,000 patient days. Such protocols should be reviewed by multidisciplinary committees to standardize enteral nutrition protocols and risk reduction for VAP.
Early gastrostomy for enteral feedings has been suggested as a strategy to reduce VAP in patients with head injury and stroke. In a small, randomized clinical trial of 20 patients with gastrostomy vs 21 control subjects, rates of VAP were reduced (10% vs 38%, respectively), and most of the VAP cases were late-onset VAP (> 5 days). Further studies with higher enrollment are needed to further assess this strategy in these high-risk patients.
Histamine type-2 (H2)-agonists and antacids have been identified as independent risk factors for ICU-acquired HAP. Sucralfate has been used for stress bleeding prophylaxis, as it does not increase intra-gastric acidity or gastric volume but is less effective in preventing GI Ыeeding.•2• Bornstain and work-ers examined risk factors for early onset VAP (from 3 to 7 days) in 747 patients. Several different variables were identified in the univariate analysis, but only sucralfate used in the first 48 h of ICU stay and unplanned extubation were predictors of VAP in the multivariate analysis; antibiotics were protective. Although the dose of sucralfate was not mentioned, and the mechanism is unclear, an increased risk of VAP was also reported in an earlier study of patients with ARDS. Data indicate that H2-blockers or proton-pump inhibitors (PPIs) are associated with lower rates of GI bleeding when compared to sucralfate, which may be important as transfusion is also a risk factor for VAP.