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Abstract

45GI = gastrointestinal; H 2 RAs = histamine H2 receptor antagonists; ICU = intensive care unit; IV = intravenous; PPIs = proton pump inhibitors; SRMD = stress-related mucosal damage.Available online http://ccforum.com/content/9/1/45 Stress ulcer prophylaxis in critically ill patientsStress-related mucosal damage (SRMD) is an erosive gastritis of unclear pathophysiology, which can occur rapidly after a severe insult such as trauma, surgery, sepsis or burns. SRMD is apparent in 75-100% of critically ill patients within 24 hours of admission to an intensive care unit (ICU) [1,2]. Clinically important bleeding, defined as macroscopic bleeding resulting in hemodynamic instability or the need for red blood cell transfusion, occurs as a result of SRMD in about 3.5% of ICU patients who are mechanically ventilated for 48 hours or more [3]. Along with mechanical ventilation, risk factors for clinically important bleeding from SRMD include coagulopathy, shock, severe burns, a history of gastrointestinal (GI) ulceration, and multiple organ failure [4,5]. Bleeding is associated with a 20-30% increase in absolute risk of mortality, and with an increase of 1-4 in relative risk [3]. In addition, it increases the demand on limited blood stocks and extends the length of ICU stay by about 4-8 days [3], thereby adding to overall management costs.To avert these consequences, prophylaxis has been recommended for all ICU patients at high risk of SRMD [4,5]. Stress ulcer prophylaxis is included in the care bundle for critically ill patients on mechanical ventilation recommended by the Institute for Healthcare Improvement and adopted by the National Health Service Modernization agency in the UK [6]. The Surviving Sepsis Campaign, an international initiative founded by the European Society of Intensive Care Medicine, the Society of Critical Care Medicine and the International Sepsis Forum, has also recommended that prophylaxis be a part of critical care [7]. Specific risk factors for SRMD include: mechanical ventilation (more than 48 hours), coagulopathy, neurosurgery, any kind of shock, respiratory AbstractProphylaxis is routinely provided for critically ill patients admitted to intensive care units (ICUs) who are at high risk for stress-related mucosal damage (SRMD), an erosive process of the gastroduodenum associated with abnormally high physiological demands. Traditionally, treatment options have included sucralfate, antacids and histamine H2 receptor antagonists (H 2 RAs). The H 2 RAs are currently the most widely used agents in prophylactic acid suppression; however, proton pump inhibitors (PPIs) have recently replaced H 2 RAs in the treatment of many acid-related conditions. PPIs achieve a more rapid and sustained increase in gastric pH and are not associated with the rapid tachyphylaxis seen with H 2 RAs. As a result, and after the introduction of intravenous formulations, PPIs are beginning to be used for the prophylaxis of SRMD in critically ill adults. The high prevalence of renal and hepatic impairment among the ICU populat...

Critical role of endogenous histamine in promoting end-organ tissue injury in sepsis

“…H 2 -receptor antagonists are widely used in critically ill patients to reduce the risk of gastrointestinal bleeding [40, 41]. Intriguingly, a significant risk for hospital-acquired pneumonia has been found for proton pump inhibitor (PPI) use but not H 2 -receptor antagonists in hospitalized patients [42], although the findings of an updated meta-analysis to evaluate the effects of PPIs vs. H 2 -receptor antagonists on clinically gastrointestinal bleeding in critically ill patients have shown no differences between drugs in the risk of pneumonia, death, or ICU length of stay [43].…”

Important drug classes associated with potential drug–drug interactions in critically ill patients: highlights for cardiothoracic intensivists

“…Proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H 2 RAs) are routinely used for critically ill subjects who are at high risk for stress-related mucosal damage (SRMD) [ 32 ]. The pH-raising effect of these GI drugs may decrease absorption and the serum concentration of azole antifungal agents (itraconazole, voriconazole, and posaconazole).…”

Variables Associated with Adherence to Stress Ulcer Prophylaxis in Patients Admitted to the General Hospital Wards: A Prospective Study

“…13-15 These studies showed high rate (56-75%) of irrational prescribing of SUP in non-ICU patients. 14 Although these studies mostly evaluated SUP administration upon admission and at discharge, but data during stay in hospital have been neglected.…”