Stress Ulcer Prophylaxis

Background

Outcomes

• these medications reduce clinically important GI bleeding
• no clear effect on mortality
• does not apply to active GI bleeds (different management)
• the aim of SUP is to prevent clinically important bleeding:
  • 1.5 to 8.5% incidence among all ICU patients
  • up to 15% among patients who do not receive stress ulcer prophylaxis

Pathophysiology of Stress Ulcers

• stress ulcers occur in the fundus and body of the stomach, but can also occur in the antrum, duodenum, distal esophagus
• shallow, oozing from superificial capillary beds
• generally begins in the proximal stomach soon after serious stressor, but only small % go on to develop voert clinical bleeding
• due to imbalance between mucosal protection and gastric acid production:
  • impaired bicarbonate-rich mucosal layer - toxins, bile salts, poor gut perfusion
  • acid hypersecretion

Indications for SUP

Consider SUP in high risk patients only as opposed to all critically ill patients. The following are identified as significant multivariate-adjusted predictors for clinically important bleeding.

1. Mechanical ventilation > 48 hours
2. Coagulopathy
   1. platelet count < 50
   2. INR > 1.5
   3. PTT > 2x control
3. History of recent GI bleeding
4. TBI, traumatic spinal cord injury
5. Burn injury
6. Two or more of: sepsis, ICU more than 1 week, occult GIB for 6 or more days, high dose hydrocortisone therapy
7. NSAIDs or antiplatelets

Approaches

Pharmacologic

• Oral PPIs are preferred over H2RBs if they can receive enteral medications.
  • pantoprazole
• If not tolerating enteral medications, use an IV H2RB (e.g. famotidine) or IV PPI.
• Sucralfate is a suitable alternative when both PPIs and H2RBs cannot be given.
• Duration should be until the patient is no longer at increased risk for stress ulceration, particularly upon discharge from the ICU

Enteral Nutrition

Enteral feeding is an alternative or addition to drugs. - improves splanchnic blood flow, improves macroscopic ulceration, stimulates GALT - studies inconsistent in showing decreased GI bleeding (low quality) - unclear if enteral feeding is sufficient protection in high risk patients

Risks of Acid Suppression

• increased nosocomial infections
  • pneumonia
  • C. difficile infection (questionable)
• drug-drug interactions
• adverse effects of PPIs (interstitial nephritis etc)

References

1. Barletta JF, Bruno JJ, Buckley MS, Cook DJ. Stress Ulcer Prophylaxis. Critical Care Medicine. 2016;44(7):1395-1405. doi:10.1097/CCM.0000000000001872
2. Cook DJ, Fuller HD, Guyatt GH, et al. Risk Factors for Gastrointestinal Bleeding in Critically Ill Patients. New England Journal of Medicine. 1994;330(6):377-381. doi:10.1056/NEJM199402103300601
3. https://www.uptodate.com/contents/stress-ulcers-in-the-intensive-care-unit-diagnosis-management-and-prevention
4. https://litfl.com/stress-ulcer-prophylaxis/