Stress ulcer prophylaxis versus placebo or no prophylaxis in critically ill patients. Pathophysiology and prophylaxis of stress ulcer in. Stress ulcer prophylaxis in hospitalized patients not in intensive care units. Stress ulcer prophylaxis is commonly administered to critically ill patients for the prevention of clinically important stressrelated mucosal bleeding from the upper gastrointestinal tract. Apart from pharmacologic approaches for stress ulcer prophylaxis sup, advances in the care of critically ill patients, such as optimal fluid resuscitation to maintain hemodynamic stability and thus improve splanchnic perfusion, and early provision of enteral nutrition en. Outcome measure of gi bleeding definition incidence clinically important gastrointestinalbleeding with spontaneous decrease in systolic blood pressure of more than 20 mmhg within 24 hours of the first gi episode. Apr 10, 2019 ashp therapeutic guidelines on stress ulcer prophylaxis. As a consequence, many critically ill patients require prophylaxis for primary prevention of bleeding from stress ulceration or treatment for stress ulcerrelated bleeding. Pathophysiology and prophylaxis of stress ulcer in intensive. Options include the acidsuppressing drugs, ppi and h2ra, or the mucosaprotective agent sucralfate. Metz mdb adivision of gastroenterology, department of medicine, university of california san francisco, san francisco, ca 94110, usa bdivision of gastroenterology, department of medicine, university of pennsylvania health system, philadelphia, pa 19104, usa. Gastrointestinal prophylaxis in neurocritical care springerlink. Therefore, we performed a metaanalysis of randomized controlled trials rcts to evaluate the effect of pharmacologic.
East practice management guidelines committee oscar d. Despite widespread incorporation of stress ulcer prophylaxis into practice around the world, questions are emerging about its indications and impact. Prophylaxis for stress ulcer bleeding in the intensive. Three hundred sixtyeight surveys were sent to all members of thesection of pharmacy and pharmacology of the society. Multiple protocols exist for prophylaxis of stress ulcer, but there are no universally accepted regiments. No surveys of stress ulcer prophylaxis prescribing in the usa havebeen conducted since 1995. Pdf guideline for stress ulcer prophylaxis in the intensive.
Stress ulcer prophylaxis with ranitidine has been associated with an increased risk of ventilatorassociated pneumonia. Measures that may help reduce the risk of ulcers include early feeding and. May 10, 2020 in 1999, the american society of health system pharmacists ashp published guidelines on the use of stress ulcer prophylaxis in medical, surgical, respiratory, and pediatric icu patients. Srmd stressrelated mucosal disease sup stress ulcer prophylaxis vte venous thromboembolism selfassessment questions answers and explanations to these questions may be found at the end of this chapter. Survey of stress ulcer prophylaxis critical care full text. Stress ulcer prophylaxis should be limited to patients considered to be at high risk for clinically important bleeding. Stress ulcer prophylaxis in the intensive care unit adult. Pdf survey of stress ulcer prophylaxis researchgate. In 1999, the american society of health system pharmacists ashp published guidelines on the use of stress ulcer prophylaxis in medical. To determine how frequently general medical patients are prescribed stress ulcer prophylaxis and what evidence exists for doing so. We identified articles through a pubmed search, covering the years 1970 to 20. Endoscopic image of bleeding duodenal ulcer with clot on top. On rounds, you have a checklist of interventions that will benefit all critically ill patients in an intensive care unit icu.
What gi stress ulcer prophylaxis should we provide. Apr 25, 2019 stress ulcer prophylaxis with a ppi vs prophylaxis with an h2 blocker found less gi bleeding among those who received a ppi 1. Diagnosis, management, and prevention and approach to acute upper gastrointestinal bleeding in adults. Stress ulcers are a known complication of a variety of critical illnesses. Vumc trauma critical care stress ulcer prophylaxis. Gastric stress ulcers are common in critically ill patients and are associated with worse outcome. Since that time, the most comprehensive metaanalysisand largest randomized study to date concerning stress ulcer prophylaxis havebeen published. Pdf to evaluate the current practice of stress ulcer prophylaxis sup in lebanese health care centers. Stress ulcer prophylaxis practice management guideline. Pdf stress ulcer prophylaxis in the intensive care unit. Uspstf strength of recommendation c the intervention is recommended selectively based upon professional judgment and patient preferences. Sucralfate is a reasonable option and reduces the risk of stress ulcerrelated bleeding.
Recommendation for the use of stress ulcer prophylaxis in neonates was removed 10. The epidemiology, pathogenesis, clinical manifestations, and prophylaxis of stress ulcers, as well as the nonsurgical treatments of upper gastrointestinal bleeding, are discussed elsewhere. Over the past decades, stress related bleeding has become extremely uncommon in intensive care unit icu patients. Srmd stress related mucosal disease sup stress ulcer prophylaxis vte venous thromboembolism selfassessment questions answers and explanations to these questions may be found at the end of this chapter. Stress ulcer prophylaxis in the icu effects associated with the use of stress ulcer ashp is currently updating their guidelines, with. Feb 04, 2016 if a stress ulcer prophylaxis is necessary, different options are available. Ashp develops official professional policies, in the form of policy positions and guidance documents for the continuum of pharmacy practice settings in integrated health systems. In the september 2009 issue of chest, zilberberg and colleagues1 reported on the association between patients receiving prolonged acute mechanical ventilation pamv and clostridium difficileassociated disease cdad. Risk factors updates in stress ulcer prophylaxis 11 cook et al. Stress ulcer prophylaxis did not decrease the risk for gi bleeding in the. Several studies have suggested that mechanical ventilation mv is one of the most significant of various probable risk factors for this condition, both in adults and children admitted to intensive care.
Stress ulcer prophylaxis in critically ill patients. The present guideline from the danish society of intensive care medicine and the danish society of anesthesiology and intensive care medicine sums up current evidence and gives clinical recommendations for sup in the icu. Sucralfate is a reasonable option and reduces the risk of stress ulcer related bleeding. The incidence, pathophysiology, risk factors, diagnostic evaluation. Stress ulcer prophylaxis cleveland clinic journal of. Stress ulcer prophylaxis sup is commonly used in the intensive care unit icu, and is recommended in the surviving sepsis campaign guidelines 2012. Krag m, perner a, wetterslev j, wise mp, hylander moller m. Stress ulcer prophylaxis sup using pharmacologic agents has since become standard therapy to prevent stress ulcer formation and bleeding in intensive care units. It is recommended by international guidelines for critically ill patients at risk of stress ulcers, and has also become increasingly common in.
The use of proton pump inhibitors has also been linked to an increased risk of communityacquired pneumonia, and pantoprazole is commonly used in stress ulcer prophylaxis. Prophylaxis for stress ulcer bleeding in the intensive care. Gastrointestinal complications of dual antiplatelet therapy. Stress ulcer prophylaxis is commonly administered to critically ill patients for the prevention of clinically important stress related mucosal bleeding from the upper gastrointestinal tract. Data source the medline database 1966 to october 2005, the cochrane central register of controlled trials 4th quarter 2005, and the bibliographies of selected articles. However, as to patients receiving enteral feeding, the preventive effect of sup is not wellknown. This has led to nationwide disorganization in current practice a stress ulcer prophylaxis. Stress ulcer prophylaxis in intensive care unit patients. Evaluate the safety and efficacy associated with histamine 2receptor antagonists and proton pump inhibitors. Stress ulcer prophylaxis in the postoperative period. The therapeutic guidelines on stress ulcer prophylaxis published by the american society of healthsystem pharmacists ashp provided clinicians with recommendations regarding appropriate candidates for stress. The primary goal of therapy related to stress ulcer is to prevent clinically important bleeding. Pharmacologic stress ulcer prophylaxis sup is recommended in critically ill patients with high risk of stressrelated gastrointestinal gi bleeding.
Sucralfate may also be an option, but is fraught with drug interactions by preventing absorption of other enteral medications. Significant bleeding may also increase the length of stay in the icu and mortality 1. Initiation of acid suppression therapy ast for stress ulcer prophylaxis sup. This recommendation came from a study by cook et al 2 in 1994, which found a significant increase in the risk of gastrointestinal blood loss in this group of patients. Stress ulcer prophylaxis has historically been a disease process with a high degree of prevalence in the setting of burns and trauma. Arrow points to the base of duodenal ulcer with active bleeding. Numerous analyses describe the role of enteral nutrition en in the prevention of stress. Gastrointestinal prophylaxis in neurocritical care. Stress ulcer prophylaxis summary the incidence of clinically important gastrointestinal bleeding due to stress ulceration has declined with advances in the resuscitation and management of critically ill patients. A medical checklist and stress ulcer prophylaxis criteria were introduced on december 22, 2014, and the patients were classified into the. Recommendations were added to consider discontinuation of stress ulcer prophylaxis in traumatic.
Pdf stress ulcer prophylaxis in critically ill patients. Describe the pathophysiology associated with stressrelated mucosal disease. Ashp therapeutic guidelines on stress ulcer prophylaxis. Guideline for stress ulcer prophylaxis in the intensive care unit. Pdf critically ill patients are at risk of developing stress ulcers in the upper digestive tract. Picus were visited on randomly defined days between april 2006 and february 2007, and the medical records of admitted patients. Effect of stress ulcer prophylaxis with proton pump. Stress ulcer prophylaxis in the intensive care unit ncbi. Stress ulcer prophylaxis in trauma patients article pdf available in critical care 66. Picture contributed by sarathchandra reddy, md, and edwin chun ouyang, md, phd, division of gastroenterology, brigham and womens. The literature regarding epidemiology and management of stress.
This was a multicenter, prospective, crosssectional observational study. Guideline for stress ulcer prophylaxis in the intensive. Pathophysiology and prophylaxis of stress ulcer in intensive care unit patients neil stollman mda, david c. To assess use of stress ulcer prophylaxis in patients admitted to five pediatric intensive care units picus in porto alegre, brazil. Identify appropriate indications for stress ulcer prophylaxis 3. Children who received prophylaxis were older and had a higher pediatric risk of mortality iii score, more often received nonsteroidal antiinflammatory drugs and systemic corticosteroids and received less enteral nutrition.
Stress ulcerations are common in intensive care unit icu patients, some of which can cause hemorrhage. A medline search was performed from the years 1990 to present with the following subject words. The aim of the supicu trial is to asses the overall benefits and harms of sup with proton pump inhibitor in adult critically ill patients in the icu. The incidence of clinically important gastrointestinal bleeding due to stress ulceration has. Ppis are more effective at keeping a constant gastric ph 4. Dec 22, 2019 ashp therapeutic guidelines on stress ulcer prophylaxis. Stress ulcers are gastric mucosal erosions that can develop in patients with a serious illness or severe injury. Stress ulcer prophylaxis is indicated for select patients grade level of quality moderate. Therapeutic position statements are concise responses to specific therapeutic issues, and therapeutic guidelines are thorough, evidencebased recommendations on drug use. The implications of recent studies for guidelines that pertain to stress ulcer prophylaxis in the postoperative period are discussed. As a consequence, many critically ill patients require prophylaxis for primary prevention of bleeding from stress ulceration or treatment for stress ulcer related bleeding. New data suggest that proton pump inhibitors suppress acid. In the january 2014 issue, eisa et al 1 suggested that patients who require prolonged mechanical ventilatory support, ie, for more than 48 hours, should receive stress ulcer prophylaxis. Conclusions and relevance among icu patients requiring mechanical ventilation, a strategy of stress ulcer prophylaxis with use of proton pump inhibitors vs histamine2 receptor blockers resulted in hospital mortality rates of 18.
Vumc trauma critical care stress ulcer prophylaxis protocol 2017. Outline jordan university of science and technology. Multiple risk factors have been associated with the. If a stress ulcer prophylaxis is necessary, different options are available. Impact of the stress ulcer prophylactic protocol on reducing the. The therapeutic guidelines on stress ulcer prophylaxis published by the american society of healthsystem pharmacists ashp provided clinicians with recommendations regarding appropriate candidates for stress ulcer prophylaxis and selection of. Maintaining adequate systemic perfusion and initiating early enteral nutrition play a significant role in preventing stress ulceration. Gastrointestinal prophylaxis, gastrointestinal hemorrhage, intensive care unit, stress ulcer prophylaxis, trauma, and critical care. Sion jo1, taeoh jeong1, jae baek lee1, youngho jin1. Recommendations were added to consider discontinuation of stress ulcer prophylaxis when patients tolerate enteral nutrition, even if other risk factors are present 11. Com 2 3 american society of health system pharmacists ashp.
There is at least moderate certainty that the net benefit is small. Stress ulcer prophylaxis was continued on the picu transfer orders for 34% of these children. We suggest using ppis when stress ulcer prophylaxis is indicated in adult critically ill patients in the icu grade 2c. Whatever agent is chosen for stress ulcer prophylaxis, the development of institutionspecific guidelines, as recommended in the ashp guidelines, has been shown to decrease inappropriate use and. Stress ulcer prophylaxis in the intensive care unit. Identify when stress ulcer prophylaxis should be discontinued 4. Delineate risk factors for stressrelated mucosal hemorrhage evaluate the efficacy and safety data between pharmacologic agents and placebo for stress ulcer prophylaxis discuss strategies to implement deimplement stress ulcer prophylaxis in clinical practice. When evaluating only the trials at low risk for bias, the evidence does not clearly support lower bleeding rates with proton pump inhibitors over histamine 2 receptor antagonists. Jun 10, 2015 stress ulcer prophylaxis sup is standard of care in the intensive care unit icu, however the quantity and quality of evidence is low and potential harm has been reported. This image was taken in a patient with a history similar to that of our patient. Stress ulcer prophylaxis litfl ccc gastroenterology. Stress ulcer prophylaxis in pediatric intensive care units.
The most relevant articles were selected using the search phrases stress ulcer, stress ulcer bleeding prophylaxis, and stressrelated mucosal bleeding in combination with intensive care unit. Stress ulcer prophylaxis in critically ill children. Stress ulcer prophylaxis sup is standard of care in the intensive care unit icu, however the quantity and quality of evidence is low and potential harm has been reported. Additional criteria and specifications were used for class i articles from a tool. Survey of stress ulcer prophylaxis article pdf available in critical care london, england 36.
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