January 7, 2019

SUP-ICU: Ending the Confusion About Stress Ulcer Prophylaxis in ICU. So I Don’t Give it Right, or do I?

Background: Stress related gastrointestinal mucosal damage is a commonly encountered problem in the critically ill patients admitted to the intensive care unit. The incidence ranges from 0.6-7% and is decreasing partly due to aggressive resuscitation strategies and focus on early enteral feeding¹. Damage to the mucosal integrity occurs in conditions associated with increased inflammation and reduced mucosal perfusion ². Despite its decreasing incidence, stress related GI bleed remains a major challenge for the intensivist with many studies showing increase in mortality and ICU length of stay in these patients³. Stress ulcer prophylaxis is recommended for critically ill patients at risk for GI bleed; the major risk factors include need for prolonged mechanical ventilation, coagulopathy, hepatic and renal failure. There is high quality evidence supporting the use of H2 receptor antagonists (H2RA) and proton pump inhibitors (PPI) in these patients. Many international surveys show that PPIs are currently preferred for acid suppression⁴. Though many randomized controlled trials support the use of PPI over other acid suppressants, there is clearly no recommendation regarding benefits of one group over the other. Alhazzani et al⁵recently published a network meta-analysis of 57 trials enrolling over 7000 patients that showed moderate quality evidence that PPIs are more effective than H2 blockers, sucralfate or placebo in preventing clinically significant GI bleed though there is a possible increase in risk for pneumonia with similar mortality. Another meta-analysis by Alshamsi et al showed that PPIs were more effective than H2RAs in reducing the risk of clinically important GI bleeding and overt GI bleeding without a significant increase in risk for pneumonia, mortality and ICU length of stay⁶ Furthermore, there is growing concern that acid suppression predisposes patients to increased risk for nosocomial infections like pneumonia and Clostridium difficile as well as cardiovascular events. This was demonstrated in a few randomized clinical trials as well as a few observational studies^7,8. The authors of the current study aimed to evaluate the benefits and adverse events associated with the use of pantoprazole for stress ulcer prophylaxis in patients at risk for gastrointestinal bleeding⁹...Read More