Helen MacDonald

Should it be the PPI group or different ones?

So to try and solve this, they did a systematic review and network meta-analysis and worked with patients and clinicians with experience of this condition to try and come up with some evidence and to contextualise that for practice.

And what they found was there was data on around 12,000 critically ill patients in this systematic review from around 72 trials that looked at both of the types of medications.

And they found that there was a reduction in clinically important bleeding.

And that that benefit was higher amongst those at higher risk of bleeding.

So in particular, patients with coagulopathy or chronic liver disease or people who were receiving mechanical ventilation but not having enteral nutrition, people with acute kidney injury, sepsis, shock, some of these conditions.

They also found that the drugs might increase the risk of pneumonia.

But even once they collected together all of the data that was out there, the quality of evidence was still quite low on that outcome.

They found that there probably wasn't a difference on actual death, but the reduction was there for bleeding.

And they found that PPIs were probably better than the H2RA agonists.

So the panel suggests that you use this particular tool to calculate the patient's risk of bleeding, and in people who have more than a 4% risk of bleeding during their stay, to use this treatment.

It's a weak recommendation, so there's still some room to personalise that and think about whether it's worth it in that particular person's case.

And that suggests that around 23 per 1,000 fewer people will have a bleed if they have the drug,

But with that comes the harm that around 50 more of those people per thousand will have pneumonia.

And overall, the authors suggest that there's still some work to do in this area, particularly around better characterising the absolute risk of C. diff infection and pneumonia in that group.

So BMJ Rapid Recommendations are produced in conjunction with the MAGIC organisation and they are a not-for-profit group who have the MAGIC app.

And if you go to the MAGIC app, what you'll find is a lot more detail than we can store on bmj.com.

So you'll find all of the outcomes listed there.

You'll also find the ability to click on the outcomes and to present it in a patient decision aid form.

That may be less helpful in this situation because people who are very sick in ITU are probably not in a position or may not be in a position to look at that information with their clinician.