RCT

REVISE

Stress Ulcer Prophylaxis during Invasive Mechanical Ventilation

NEJM, 2024 · International randomized placebo-controlled trial (n=4821)

Clinical question

Does pantoprazole prevent clinically important upper GI bleeding without increasing mortality in invasively ventilated ICU patients?

Population: Critically ill adults receiving invasive mechanical ventilation
Intervention: Pantoprazole 40 mg IV daily
Comparator: Placebo
Primary outcome: Clinically important upper gastrointestinal bleeding; 90-day mortality was the primary safety outcome
Result: Clinically important upper GI bleeding: 1.0% pantoprazole vs 3.5% placebo (HR 0.30, 95% CI 0.19–0.47); 90-day mortality 29.1% vs 30.9% (HR 0.94, 95% CI 0.85–1.04).

What the trial found

Pantoprazole substantially reduced clinically important upper GI bleeding without a statistically significant effect on 90-day mortality.

Current guideline position

Major contemporary RCT informing ICU stress-ulcer prophylaxis.

Clinical interpretation

For invasively ventilated ICU patients with an indication for stress-ulcer prophylaxis, PPI prophylaxis reduces clinically important upper GI bleeding; reassess and discontinue when the ICU indication resolves.

Clinical Context & Relevant Topics (2)

Disease Reference

Upper Gastrointestinal Bleeding (UGIB)

Risk-stratified non-variceal and variceal hemorrhage care: resuscitation, selective airway protection, individualized transfusion, PPI or portal-pressure therapy, endoscopic hemostasis, and escalation to IR/TIPS/surgery when indicated.

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Invasive Mechanical Ventilation

Complete clinical topic overview. For the full 10-level interactive course, visit Master MV. Covers core ventilator modes, respiratory mechanics (Cstat, Raw, driving pressure), waveform dyssynchrony analysis, VILI prevention, and liberation protocols.

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