Stress Ulcer Prophylaxis
VBMC TRAUMA CARE SERVICES GUIDELINE
Stress Ulcer Prophylaxis
Purpose: To provide clinicians with evidence-based recommendations for
initiation and discontinuation of pharmacologic stress ulcer prophylaxis
(SUP)
Section 1: Indication of Pharmacologic Stress Ulcer Prophylaxis Therapy
1. SUP is recommended in
the following situations:
a. Patients when
mechanical ventilation for more than 48 hours is likely (Strong Recommendation,
High Quality of Evidence)
b. Coagulopathy defined as
platelet count < 50,000/μL, INR > 1.5, or PTT > 2 times the control
value while not on exogenous anticoagulation (Strong Recommendation, High
Quality of Evidence)
c. Acute traumatic brain
injury with Glasgow Coma Score ≤10 or inability to obey simple commands (Strong
Recommendation, Moderate Quality of Evidence)
d. Major thermal injury
(≥20% of total body surface area) (Strong Recommendation, Moderate Quality of
Evidence)
2. SUP may be considered
in the following situations:
a. Acute spinal cord
injury (Conditional Recommendation, Low Quality of Evidence)
b. Partial hepatectomy in
the ICU (Conditional Recommendation, Low Quality of Evidence)
c. Spontaneous
subarachnoid hemorrhage, particularly in those with high risk of cerebral
vasospasm (or vasospasm present) (Conditional Recommendation, Low Quality of
Evidence)
d. History of GI
ulceration or bleeding within 12 months before admission to the ICU
(Conditional Recommendation, Very Low Quality of Evidence)
Section 2: Selection of Pharmacologic Stress Ulcer
Prophylaxis Agent:
1. A
histamine H2 antagonist (H2RA) or proton pump inhibitor (PPI) are considered
first-line agents for SUP (Strong Recommendation, Moderate Quality of Evidence)
a. Either
a H2RA or PPI may be given first line for SUP and clinicians should use patient
specific factors to guide agent selection (Conditional Recommendation, Very Low
Quality of Evidence)
2. Sucralfate
is an alternative agent for adults unable to tolerate an H2RA or PPI (Moderate
Recommendation, High Quality of Evidence)
3. An
oral or enteral route is preferred for both PPIs and H2RAs when feasible.
(Strong Recommendation, Low Quality of Evidence)
Section 3: Discontinuation of Pharmacologic Stress
Ulcer Prophylaxis Therapy:
1. SUP
should be discontinued if a patient no longer meets an indication listed in
Section 1 and does not have an alternate indication (examples included in Table
3) (Strong Recommendation, Moderate Quality of Evidence)
a. Clinicians
should assess the indication for stress ulcer prophylaxis daily, upon admission
and discharge, and upon a change in the level of care (Strong Recommendation,
Moderate Quality of Evidence)
b. Discontinuation
of unnecessary therapy is warranted as acid-suppressive agents have been
associated with an increased risk of pneumonia, Clostridium difficile,
drug-drug interactions, nutritional deficiencies, and increased costs (Strong
Recommendation, Moderate to High Quality of Evidence)
2. SUP
may not provide added benefit in patients tolerating enteral nutrition defined
as >50% of goal feeds due to improved splanchnic blood flow and possible
reduction in gastrointestinal bleeding rates (Conditional Recommendation, Low
Quality of Evidence)
a. Literature
is unclear regarding the location of feeds (gastric versus post-pyloric) and
the effects of reducing the risk for ulceration
b. It
may be reasonable to continue SUP therapy despite enteral feeding in patients
exhibiting hypersecretory states (i.e. burns, traumatic brain injury)
c. Clinicians
are encouraged to individually weigh the risk-benefit assessment when deciding
whether to continue or withhold SUP for patients tolerating enteral feeds
3. Considerations
should be made for additional indications for H2RA or PPI therapy based on
based medical history or current conditions
References
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