Commonly employed medications used in critically ill patients requiring life support include proton pump inhibitors (PPIs). These medications are thought to prevent gastrointestinal (GI) bleeding from stress-induced ulceration. Despite their widespread use, they do hold some risks which include infection in the form of pneumonia and diarrheal illnesses such as Clostridioides difficile infection (C. difficile). Emerging high-quality studies suggest PPI usage does not influence susceptibility to COVID-19 infection, however some studies suggest PPI use leads to poor outcomes in this population, including prolonged time on life-support and death. While we can appreciate the negative effects of PPI may be magnified in the sickest of patients, namely hospitalized patients with COVID-19, the beneficial or potentially harmful role they play in this population remains unclear. We aim to build a clinical profile to further describe critically ill patients with COVID-19 in Ontario using the infrastructure of an ongoing multicenter clinical trial of acid suppression. We will identify characteristics that predict poor outcomes among sick COVID patients, examining the impact of PPIs on this population.
The overall aims are to further characterize the high-risk population of COVID-19 patients nested within the multicenter REVISE trial. Specifically, we plan 1) to explore the impact of PPIs on mechanically ventilated critically ill COVID-19 patients, 2) describe the clinical course for patients with COVID-19 and identify characteristics that predict poor prognosis, and 3) compare outcomes to patients without COVID-19. The overall research questions are as follows: 1. Do critically ill patients projected to receive mechanical ventilation for \>48 hours with COVID-19 have different clinical outcomes without PPIs? 2. Are there prognostically relevant demographic, biomarker and clinical data to characterize critically ill patients with COVID-19? 3. Do critically ill patients with COVID-19 have significant higher rates of clinically important GI bleeding, 90-day mortality, and rates of infection when compared to a propensity-matched non-COVID REVISE cohort? To accomplish this, the investigators propose to gather information in patients' medical charts including biomarkers drawn by the ICU team, venous thromboembolism (VTE) and tracheostomy timing, to link with extensive baseline characteristics and outcomes already collected in the REVISE trial (NCT03374800)
Study Type
OBSERVATIONAL
Enrollment
600
Following the intervention of the Re-EValuating the Inhibition of Stress Erosions (REVISE) Trial (NCT03374800)
St Joseph's Healthcare Hamilton
Hamilton, Ontario, Canada
RECRUITINGRate of clinically important gastro-intestinal bleeding
The primary efficacy outcome is clinically important GI bleeding occurring in the ICU or resulting in ICU readmission during the index hospital stay. The definition of clinically important GI bleeding is overt GI bleeding (i.e., hematemesis, frank blood or coffee ground nasogastric aspirate, melena or hematochezia) plus 1 of the following in the absence of other causes: 1. Hemodynamic change defined as a spontaneous decrease in invasively monitored mean arterial pressure or non-invasive systolic or diastolic blood pressure of \>20 mmHg, or an orthostatic increase in pulse rate of \>20 beats/minute and a decrease in systolic blood pressure of \>10 mmHg, with or without vasopressor initiation or increase; 2. vasopressor initiation; 3. hemoglobin decrease of \>2 g/dl (20 g/L) within 24 h of bleeding; 4. transfusion of \>2 units red blood cells within 24 h of bleeding; or 5. therapeutic intervention (e.g., therapeutic endoscopy, angiography, surgery).
Time frame: 90 days
Primary Safety Outcome: 90 Day Mortality
Mortality status at day 90 post randomization
Time frame: 90 days after randomization
Ventilator-associated pneumonia
VAP is diagnosed in patients who received invasive mechanical ventilation for \>48 hours when there is a new, progressive or persistent radiographic infiltrate plus at least 2 of the following without other obvious cause: 1) fever (temperature\>38 °C) or hypothermia (temperature \<36 °C); 2) leukopenia (\<4.0x106/L) or leukocytosis (\>12x106/L); 3) purulent sputum; or 4) gas exchange deterioration.
Time frame: 90 Days (while in ICU,censored at 90 days after randomization)
C. difficile infection
Defined as clinical features (diarrhea \[\>3 episodes of unformed stools or Bristol type 6 or 7), ileus, or toxic megacolon) and either microbiological evidence of toxin-producing C. difficile or pseudomembranous colitis on colonoscopy in hospital.
Time frame: 90 days (during the index hospital admission, censored at 90 days)
Renal replacement therapy
Defined as initiation of new renal replacement therapy in the ICU.
Time frame: While in ICU,censored at 90 days after randomization
Hospital mortality
Defined as all-cause mortality in hospital.
Time frame: While in hospital, censored at 90 days after randomization
Patient important GI bleeding
Defined as overt GI bleeding, plus an invasive intervention (e.g., therapeutic endoscopy, angiography, surgery), acknowledging how some clinically important GI bleeds in prior studies did not actually require any tests or treatments, and thus may not be important to patients. This outcome will be refined by an ongoing mixed methods study with an overarching instrument-building aim.
Time frame: Censored at 90 days after randomization
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