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. ix 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.