Mind the gut: Navigating the complex landscape of gastroprotection in neurosurgical patients

Table 1 Risk factors for stress ulcer and upper gastrointestinal bleeding in the neurocritical cohort

No.	Risk factors
1	Glasgow coma scale < 9[3,10,11]
2	Age > 60 years[8,9]
3	Syndrome of inappropriate anti diuretic hormone[8]
4	Pyogenic central nervous system infection[8]
5	Elevated plasma cortisol[12]
6	Cerebral vasospasm[13]
7	Elevated intracranial pressure[13]
8	Mechanical ventilation > 48 hours[13]
9	Organ failure (renal, hepatic)[9]
10	Hypotension[9]
11	Coagulopathy[9,13]

Table 2 Summary of randomized trials on gastroprotection in neurocritical patients

No	Ref.	Year	Study population	N	Intervention arm 1 (n)	Intervention arm 2 (n)	Intervention arm 3 (n)	Endpoints	Findings
1	Halloran et al[28]	1980	Severe TBI patients	50	Cimetidine (26)	No prophylaxis (24)	-	GIB (NGT aspirate positive for blood)	Overt GIB significantly lower in arm 1 compared to arm 2
2	Reusser et al[25]	1990	TBI and surgically managed ICH patients	40	Ranitidine (21)	No prophylaxis (19)	-	Gastric pH > 4, endoscopic findings of ulcer, blood in NGT aspirates	No difference in rate of stress ulcers or GIB between both arms
3	Metz et al[9]	1994	TBI patients	167	Ranitidine (86)	No prophylaxis (81)	-	GIB (NGT aspirate positive for blood or malena/hematochezia). Nosocomial pneumonia	Overt GIB significantly lower in arm 1 compared to arm 2. No difference in rates of pneumonia
4	Burgess et al[27]	1995	TBI patients	34	Ranitidine (16)	No prophylaxis (18)	-	GIB (NGT aspirate positive for blood or malena/hematochezia)	Overt GIB significantly lower in arm 1 compared to arm 2
5	Chan et al[26]	1995	Non traumatic neurosurgical patients	101	Ranitidine (48)	No prophylaxis (52)	-	Serial endoscopic assessment to determine bleeding requiring transfusion or surgery	Overt GIB significantly lower in arm 1 compared to arm 2
6	Misra et al[7]	2005	ICH	141	Ranitidine (45)	Sucralfate (49)	No prophylaxis (47)	GIB (hematemesis, NGT aspirate positive for blood or malena/hematochezia), 1 month mortality	No difference in GIB or 1 month mortality between arm 1, arm 2 compared to arm 3
7	Brophy et al[34]	2010	All patients admitted to the neurosurgery ICU	51	Lansoprazole (28)	Famotidine (23)	-	The pH ≥ 4 and % of time gastric residuals was < 28 mL	Arm 1 achieved pH ≥ 4 and fewer heme-positive aspirates more often than arm 2 only on day 1
8	Liu et al[37]	2013	Surgically treated ICH patients	165	Omeprazole (58)	Cimetidine (54)	No prophylaxis (53)	UGIB hematemesis, aspiration of coffee-ground material from NGT or positive gastric occult blood or fecal occult blood testing, with or without hemodynamic instability from gross bleeding needing transfusion). Nosocomial pneumonia incidence	Lower rate of UGIB in arm 1 compared to arm 2 and 3. No difference in rate of nosocomial pneumonia
9	Lee et al[35]	2014	Neuro ICU patients admitted post-op or Canonical Variates Analysis management	60	Esomeprazole (30)	Famotidine (30)	-	Overt GIB and VAP	1 patient in arm 2 developed GIB and 1 from each arm developed VAP
10	Senapathi et al[36]	2019	TBI patients with Glasgow coma scale < 10	56	Omeprazole (28)	Ranitidine (28)	-	Time to gastric pH > 3.5-5.0 and occult from NGT aspirates	No significant difference in endpoints between both arms

GIB: Gastrointestinal bleeding; ICH: Intracerebral hemorrhage; ICU: Intensive care unit; NGT: Nasogastric tube; TBI: Traumatic brain injury; UGIB: Upper gastrointestinal bleeding; VAP: Velocity average path.