Grade A Recommendation The use of ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation.
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Author info
Posted By:	Gordon S. Doig
E-Mail:	Gordon.Doig@EvidenceBased.net
Posted Date:	25/02/2002
Title:	The use of ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation.
PubMed Resource Link:	Click here to repeat the Medline search used to develop this EBR.
Evidence-based Recommendation
Best level of evidence
	Well conducted, well powered Level I RCT.
Target Population
	All patients expected to receive mechanical ventilation for greater than 48 hours.
Purpose
	To reduce the rate of clinically important gastrointestinal bleeding by 2.1% (ARR compared with sucralfate). 47 patients would need to be treated with ranitidine to avoid 1 clinically important GI bleed.
Exclusion criteria
	1) Pre-existing diagnosis of GI bleeding.
Recommendation
	At the onset of ventilation, every patient who is expected to be ventilated for greater than 48hours should receive ranitidine: 1) standard dose: 50 mg IV every 8 hours 2) for patients with estimated creatinine clearance rate of 25 to 50 ml per minute 50mg IV every 12 hours 3) for patients with an estimated creatinine clearance rate below 25 ml per minute 50mg IV every 24 hours 4) dialysis dependent patients 50mg IV every 12 hours
Potential harm
	A review of meta-analyses suggests that the use of ranitidine (compared to sulcrafate) may be associated with an increase in ventilator associated pneumonia (OR 1.51, 95% CI 1.00 to 2.29, p=0.05). However these meta-analyses considered many older, smaller trials that used various different approaches to establish the diagnosis of VAP. The results of these meta-analysis are not supported by the findings of the most recent methodologically rigerous trial conducted by Cook et al.
Development Information
Date EBR last updated
	April 15, 2003.
Literature source and search terms
	Medline searched using PubMed from 1966 to Feb 25, 2002 with the following terms: Anti-ulcer agents/therapeutic use AND (critical* OR intensive* OR intensive care OR intensive care units OR "intensive therapy" OR critically ill OR critical illness OR critical care) AND (random* OR "systematic review*" OR meta-analysis OR guidelines OR randomized controlled trials OR randomized controlled trial OR systematic [sb]) NB- PubMed automatically maps these terms to their MESH headings and expands any terms ending with '*'.
Study selection
	All 263 abstracts were hand searched for articles reporting clinically meaningful outcomes. There was only one well performed level I RCT reporting clinically meaningful outcomes. A recent meta-analysis was reviewed to ascertain the contributions of all Level II RCTs.
References
	A comparison of sucralfate and ranitidine for the prevention of upper gastrointenstinal bleeding in patients requiring mechanical ventilation. N Engl J Med 1998;338:791-7 (Level I) Bleeding and pneumonia in intensive care patients given ranitidine and sucralfate for prevention of stress ulcer: Meta-analysis of randomised controlled trials. BMJ 2000;321:1-7 (Level II+) The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients. Crit Care. 2001; 5 (6): 368-375 (Level III) Prevention of ventilator-associated pneumonia: an evidence-based systematic review. Ann Intern Med. 2003 Mar 18;138(6):494-501 (Review)
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